Both a rational pharmacologic approach and nonpharmacologic plan can be developed using the information obtained from the pain assessment. The rational pharmacologic approach, called multimodal analgesia, is the administration of combinations of analgesics with differing mechanisms of action to provide analgesia with lower doses and fewer side effects.10 For example, a nonsteroidal anti-inflammatory drug with an opioid and acetaminophen (Tylenol) block pain at different sites along the pain pathway. NSAIDs block prostaglandin at peripheral nociception. An opioid blocks pain at the opiate receptors at the periphery, the substantia gelatinosa of the dorsal horn of the spinal cord, and the periaqueductal grey region of the brain. High doses of acetaminophen (3,000 to 4,000 mg/day) block pain at the descending serotonergic path. Other interventions to consider that may enhance pain management via multimodal analgesia are nerve blocks using local anesthetic agents, or intraspinal analgesia using opioids alone or in combination with local anesthetic agents. These interventions can be used in concert with opioids and nonopioid analgesics administered systemically and with the supervision of an anesthesiologist. 

Another category of medications that can be used as adjunct analgesia is the α2 δ-ligands, such as gabapentin (Gralise, Horizant, Neurontin, generics) and pregabalin (Lyrica, generics). These medications produce analgesia by way of neuronal membrane stabilization at voltage-gated Ca2+ channels along the peripheral nerve. The mechanism of action is proven to be effective in inflammatory pain, neuropathic pain, and in reducing postoperative pain when given both preemptively and postoperatively.11

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Many medications are available to block pain at various pain pathways. The agents discussed in this article are not an exhaustive list of medications used to treat pain. The following guiding principles for effective pain management summarize the factors to consider when developing a rational pharmacologic approach to pain management.12

  • Understand that pain is a subjective experience involving the biological, psychological, social, and spiritual components of a person’s life.
  • Pain does not usually occur in isolation from other symptoms; the associated symptoms also need to be assessed and managed (ie, nausea, dyspnea, etc.).
  • Assessment should be comprehensive, individualized, and holistic involving input from the multidisciplinary team.
  • Patient and caregiver should be involved in the assessment and planning of various interventions used.
  • The etiology of the pain may not be known, however, attempts to determine the etiology must be compatible with the patient’s goals.
  • Oral analgesia should be the preferred route of delivery when possible, titrated until pain is relieved, and given regularly when pain is persistent.
  • Morphine is considered the standard-of-choice opioid. However, if comorbid illness exists, such as renal insufficiency, an opioid with less active metabolites may be preferred to reduce side effects.
  • When pain is continuous, so must the analgesia be continuous, with breakthrough pain medications available.
  • Adjuvant medications must be considered based on the assessment and the neuro-mechanisms involved with the pain.


Nonpharmacologic modalities can be used with a pharmacologic approach to pain management. These strategies can be very effective in relieving pain and providing comfort while empowering the patient and family to deliver pain relief in a safe manner. Nonpharmacologic modalities include, but are not limited to, relaxation techniques, superficial heating or cooling, acupuncture, reflection and spirituality, and pacing.13

Relaxation can be learned but not forced. It involves letting go of stressful thoughts and thinking pleasant thoughts. Techniques used to assist in relaxation can help with both acute, chronic, and cancer pain. Muscle relaxation techniques include shoulder shrugs, head circles, shoulder rolls, and arm and fist tightening/relaxation. These techniques serve to focus the mind and should be performed in a quiet, comfortable, warm room. 

Superficial heating and cooling via applying hot or cold packs is effective for localized pain. Although the underlying mechanism is unknown, heat or cold is believed to relieve pain by easing muscle tension or reducing swelling, respectively.14 The patient should be educated to protect the skin against prolonged exposure, and resultant tissue injury. 

Acupuncture is the therapeutic placement of needles along the meridian system. Evidence supports that acupuncture releases endogenous opioid peptides, thus creating analgesia.15 Education standards for physician and nonphysician acupuncturists are established through agencies at the state level. Health insurance reimbursement, however, varies and should be investigated for the patient. 

Reflection allows the patient to acknowledge and honor their feelings as they arise. Painful memories or thoughts can increase stress, and pain becomes worse. Reframing uncomfortable feelings with pleasant ones reduces stress and allows further relaxation. Spiritual health may be important to the palliative care patient and providing support for spiritual health can assist in healing. Through their spirituality, the patient can make sense of and give meaning to their suffering and their lives. 

Pacing is done through interrupting activity for short and frequent breaks. These breaks allow patients to change position, practice deep breathing for relaxation, stretch, and avoid feeling rushed and anxious by slowing the pace of activity. Energy conservation is part of pacing and can be taught to patients and their caregivers. This not only helps improve the patient’s pain but also associated symptoms such as dyspnea. The steps to energy conservation are

  • Eliminate unnecessary tasks.
  • Avoid unnecessary bending, reaching, or walking.
  • Avoid lifting objects by sliding them along a counter or using a cart.
  • Pack grocery bags so they are not too heavy, and place them in a rolling cart when possible.
  • Do not overload purses or briefcases.
  • Avoid using shoulder bags, as these may throw off balance and cause more pain.13

 TABLE 2. Pain management resources

 American Society for Pain Management Nursing (ASPMN)
 Position statements from the ASPMN
 Information for patients and caregivers
 A Patient Resource Guide: Reducing Your Pain
 A digital publication on pain management
 Resources For People in Pain
 Links to resources and information on pain management


The suffering that occurs from pain encompasses all of the patient’s physical, psychological, social, spiritual, and daily struggles.16 Pharmacologic analgesia can be used to block the pain pathway, thereby relieving pain. Nonpharmacologic interventions can enhance pain management, individualize the patient’s treatment plan, and empower the patient and their caregivers to use techniques that do not require medical or nursing intervention (Table 2). An effective pain management plan uses both pharmacologic and nonpharmacologic interventions in combination to achieve pain relief and enhance patients’ quality of life. ONA 

Acknowledgement: Work for this paper was partially supported by NIH Grant T32NR011147 at the University of Iowa, College of Nursing, Iowa City, Iowa. 

Barbara St. Marie is supervisor, Pain and Palliative Care, and adult and gerontology nurse practitioner, Pain Management, at the University of Minnesota Medical Center, Fairview in Minneapolis, Minnesota, and Fairview Ridges Hospital, Burnsville, Minnesota. 

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1. International Association for the Study of Pain. Proposed taxonomy changes.
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13. Fairview Press. When Your Pain Flares Up. Minneapolis, MN: Fairview Press; 2002.

14. Vanni L, Rehm MN (2010). Cancer Pain Management. In St. Marie BJ, ed. Core Curriculum for Pain Management Nursing. 2nd ed. Dubuque, IA: Kendall Hunt Publishers; 2010:461-479.

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16. Dame Cicely Saunders. BMJ. 2005;331(7510):238. Accessed June 3, 2013.

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