Chronic wound pain and procedural pain issues are well studied and documented, but novel, affordable procedural pain management options are lacking. This author discusses emerging wound-related pain management trends, including current procedural and operative pain management best practices for wound care providers.
Managing your patient’s pain properly is arguably one of the most effective methods to improve your team’s relationship with patients and referral providers. Patients describe wound-related pain as all-encompassing, and one of the most devastating aspects of living with a chronic wound. The European Wound Management Association (EWMA) identifies dressing removal as the time of most significant perceived pain. Pain is known to be more intense during dressing changes and can take up to two hours to subside.1 Patients often report the pain associated with a procedure to be worse than the condition necessitating the procedure.2
Is the Pain Nociceptive, Neuropathic or Mixed?
Nociceptive pain is a physiological response that occurs when sensory receptors react to painful stimuli. For example, mechanical trauma and prolonged inflammation resulting from tissue injury.
Neuropathic pain results from damage or dysfunction to the peripheral or central nervous system. Nerve damage is the most common cause of allodynia and is associated with any sensory stimulus such as light touch, pressure, or even changes in temperature.
Mixed pain is a combination of nociceptive and neuropathic pain. When possible, treatment plans should include a bio-psycho-social approach, specifically taking into consideration the difference in mechanism of action between neuropathic and non-neuropathic agents.3
A Closer Look at Current Pain Management Methods
• Non-pharmacological methods to prevent or avoid pain4
• Physical therapy, psychological therapy, cognitive behavioral therapy, and complementary therapy to help reduce stress during dressing changes5
• AAA Meds: analgesic, anxiolytic, & anti-inflammatory (see Table 1)
Benefits of Effectively Managing Pain
All parties involved benefit when patient pain management is a priority:
• Improved experience with the wound care provider
• Increased treatment plan adherence
• Improved confidence in the care team
• Decreased anxiety and posttraumatic stress disorders
• Improved quality of life
Wound care providers
• Easier dressing changes
• Improved patient adherence in the treatment plan and its associated dressing changes
• Improved wound healing outcomes
• Decreased reliance on social defenses such as “distancing” from and “denial” of patient pain
Wound clinics (including hospitals, home health agencies, skilled nursing facilities)
• Decreased dressing and operational costs when shifting to pain management products that are covered by prescription insurance
• Increased referrals from referring facilities and providers due to a rise in positive feedback received from their patients on baseline and procedural pain management
• Pain management used as a marketable initiative to referral sources
• Improved patient satisfaction scores and quality performance scores
• Decreased hospital readmittance due to reduced patient treatment non-adherence
Notable Active Ingredients Used in Topical Wound Pain Management
One of the most exciting concepts in procedural pain management is the use of prescription-strength transdermal (topical) medications. Transdermal delivery allows a convenient, non-invasive way to manage difficult types of chronic pain. Side effects and drug interactions are minimized because, unlike oral or injected medications that require high blood levels to achieve effectiveness, topical formulations are designed to provide high tissue concentrations without significant systemic absorption.
In the past, topical medications have had relatively poor bioavailability, limiting their effectiveness. However, the development of a new generation of transdermal formulations allows medications to readily penetrate the epidermis, directly targeting the site of injury. Topical medications have an increased duration of action compared to other routes of administration due to the skin acting as a drug reservoir, allowing for a slower release of the drug over time. Topical drug forms are not all creams and gels either—polyox-bandages (dry powders) include methylcellulose, which slows down drug delivery to the wound, meaning the duration of pain relief is improved.6
Consider selecting thermoreversible topical pain relief products, which liquefy at cooler temperatures and gel at warmer temperatures. This allows you to debride wounds with room temperature sterile saline, which is less painful for your patient.7
For baseline pain relief, consider the drug form, onset, and duration of action of the pain treatment. Is it in line with your patient’s needs and current lifestyle? Treat the underlying condition. Is the pain ischemic (requiring urgent revascularization) or neuropathic (requiring antiepileptics)? Develop and implement a comfort management plan for after the procedure because the pain resulting from the procedure itself may not subside when the procedure is completed and must be treated appropriately.2
How to Treat Pain Locally and Regionally
The human body is composed of individual skin segments or dermatomes. Each dermatome contains bundles of nerve fibers, which transmit sensory data such as touch, temperature, and pain to a particular vertebra on the spine, and from there to the brain. Returning nerve signals travel from the brain, down the spinal cord, and then through the nerves in the dermatome to control functions such as muscle movement.
For optimal procedural pain relief, treat pain locally and at the appropriate dermatome. Wound care providers can both treat the cause of pain at the injury site and block pain perception at the spinal cord level by applying the medication directly to the spinal segment of the involved dermatome. This works to block pain signals from reaching the brain. Using the right combination of active ingredients in the most appropriate dosage form, wound care providers can help their patients control their pain better while decreasing their reliance on oral or IV pain medications (see Table 2).
Armed with an understanding of how nerves transmit and receive signals from the dermatome to the spine, it is easy to see how blocking pain transmission at the appropriate dermatome will provide your patient much-needed pain relief.
The cream will slowly work its way through the subcutaneous tissues to the correct site of action. Do not be too concerned about not knowing the exact spot to apply the creams—if you get the cream close to the area, it will still be effective.
Considerations With Cost
While OTC pain management options are known to be affordable, their efficacy is unfortunately also limited. Prescription grade strength and efficacy unsurprisingly require a prescription. Whereas prescription insurance plans usually cover generic medications without issue, compounded medication coverage has decreased over time. Nevertheless, prescription-grade treatment options remain affordable for patients and wound providers alike, because the cost of inadequate pain management not only hurts the patient needlessly, but also contributes to delayed wound healing, patient treatment non-adherence, and increased dressing, payroll, and overhead costs.
Practical Actions You Can Take
• Ensure your patient has at least 5 different types of providers, including a wound care specialty pharmacy, involved in their wound care. Effective wound care is a multidisciplinary approach requiring a thorough assessment from different lenses
• Treat procedural pain locally at the site of the wound and at the dermatome for optimal pain management
• Create an analgesic regimen that includes pain assessment tools taking into consideration a patient’s background pain while providing pain relief before, during and post-procedure
Patients put their trust in health care professionals and should not have to face the trauma of repeated painful dressing changes.1 Health care professionals need to rise to the challenge of minimizing wound pain, selecting the appropriate wound care products, and having an understanding of the uses, indications, and contraindications of a wide range of products.1
Try not to fit a square peg into a round hole—every patient’s pain management needs are different. Wound care providers should customize a pain management care protocol around the patient’s wound while taking into consideration their patient’s feedback to prevent pain, treat the cause of pain effectively, and best manage pain symptoms with products containing the most appropriate active ingredients and dosage form for their patient’s wound needs.
There continues to be a need for a better way to manage procedural pain that can be applied daily or with dressing changes. If you are not a prescribing provider, work with a local wound care specialty pharmacy to help you request the appropriate pain management option—your patients will thank you for it.
Dr. Survam Patel is a licensed pharmacist and the managing partner of Smithville Pharmacy in central Texas, specializing in customizing anti-infectives and pain treatments for wound providers and patients. For more information or a provider consultation, he can be reached at email@example.com.
1. Edwards J. Dealing with wound-related pain at dressing change. J Comm Nurs. 2013; 27(4):36–42.
2. Czarnecki ML, Turner HN, Collins PM, et al. Procedural pain management: a position statement with clinical practice recommendations. Pain Manag Nurs. 2011; 12(2):95–111.
3. Ritchie M. Mixed pain. GM. Available at https://www.gmjournal.co.uk/media/21867/gmdec2011p624.pdf . Published December 2011.
4. Romayne G. The management of wound-related procedural pain (volitional incident pain) in advanced illness. Curr Opin Support Palliat Care. 2013; 7(1):80–85.
5. Sardina D. Ouch! That hurts! Wound Care Advisor. Available at http://woundcareadvisor.com/best-practices-vol1-no3/ .
6. Vlaia L, Coneac G, Olariu I, et al. Cellulose-derivatives-based hydrogels as vehicles for dermal and transdermal drug delivery. From Majee SB (ed.) Emerging Concepts in Analysis and Applications of Hydrogels. IntechOpen, 2016.
7. No authors listed. How to make dressing changes less painful. Adv Skin Wound Care. 2004; 17(1):42–43.