Pain Management Challenges in Acute and Critically Ill Patients

Most acute and critically ill patients experience pain during their care. Pain management remains a daily challenge to care teams because high levels of pain are often reported by these patients, and a significant proportion of acute and critically ill patients cannot communicate. Adequate treatment of acute pain based on a multimodal analgesic approach is essential to provide appropriate pain relief to patients, to optimize their recovery, and to prevent chronic pain development. Indeed, acute pain is an important risk factor for chronic pain, both of which have substantial impact on quality of life and daily functioning. Also, the use of opioids in the treatment of acute pain is not without risks; it can lead to long-term use, misuse, and opioid use disorder (OUD), which adds to the challenges of pain management.¹  The opioid crisis in North America^2–4  has become a global health priority. Safe use of opioids and prevention of opioid-related deaths and harms are essential to providing safe and optimal care to patients and families.

In this series of 7 articles based on the most up-to-date evidence, we address important challenges and major gaps related to pain management in acute and critically ill patients. The first article, by Mélanie Bérubé, is a review of acute to chronic pain transition and its prevention, which is a high priority of the Institute of Medicine of the National Academies.⁵  Bérubé describes the pathophysiology, epidemiology, risk factors, and consequences of acute to chronic pain transition as well as the role of nurses in preventive interventions in acute and critically ill patients. The second article, by Barbara St. Marie, describes the assessment of a patient’s risk for OUD and opioid misuse using validated tools and other strategies to monitor ongoing opioid misuse. In the third article, Peggy Compton discusses strategies for effective acute pain management in patients on medication-assisted therapy, an evidence-based approach for the treatment of OUD.

The next four articles in the series examine the evidence available on pain management in critically ill adults and address complex topics and major gaps highlighted in clinical practice guidelines related to pain management.⁶  The fourth article, by Carmen Mabel Arroyo-Novoa and colleagues, addresses iatrogenic withdrawal syndrome (IWS) related to the use of opioids and benzo-diazepines in critically ill adults. They describe identification of risk factors, assessment of withdrawal symptoms, and a clinical approach to preventing and treating IWS. The fifth article, by Céline Gélinas and colleagues, provides an updated comprehensive review and psychometric analysis of 13 behavioral pain assessment tools for use in noncommunicative critically ill adults. Psychometric evidence evolves rapidly as more validation studies are published; this updated review provides useful information to nurses and care teams to guide them in the selection of robust valid tools for clinical practice. This psychometric analysis is also aligned with the International Association for the Study on Pain’s 2019 Global Year Against Pain in the Most Vulnerable.⁷  The sixth article, by Geraldine Martorella, is a scoping review of the characteristics of nonpharmacologic interventions for pain management in the intensive care unit (ICU). These interventions are part of a multimodal analgesic approach, and their use is strongly recommended in clinical practice guidelines⁶  and in the ICU Liberation Bundle⁸  because they are simple and safe to use, and can be initiated by nurses. Finally, the last article of the series, by Emilie Gosselin and Melissa Richard-Lalonde, addresses the role of the family in the assessment and management of pain in critically ill adults. In this descriptive review, Gosselin and Richard-Lalonde examine the available evidence and discuss implications for clinical practice, education, and future research.

This series on pain management challenges led by US and Canadian authors is unique and timely. Indeed, it offers important updates on key topics as well as relevant assessment tools, strategies, and interventions for nurses and care teams to use and to help them provide the best and safest care to patients and families.