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Addressing the Pain: Local Approaches to the Pain of Pressure Ulcers
Pressure ulcers may not need continuous analgesia. Pain relief may be more appropriate at certain times, such as before dressing changes, when patients may anticipate pain similar to what has been previously experienced. Thinking “local” rather than systemic may be of benefit in many cases.
When deciding on the best approach, clinicians should be mindful that systemic administration of opioids can cause a myriad of adverse effects and still not control the pain generated by a pressure ulcer. Increasing evidence points to the beneficial effects of topically applied opioids, which lack the adverse effects and toxicity of their systemically administered counterparts. Stein and colleagues1-4 showed in animal and human studies that peripheral opioid receptors exist. Their studies suggest that the presence of inflammation is critical for the recruitment and activation of opioid receptors. Because a pressure ulcer is an inflammatory lesion,5 topical opioids (using a hydrogel as a transport media) may be an alternative in management of pressure ulcer-related pain.6
Another safe alternative to systemic opioids is the lidocaine patch 5% (Lidoderm, Endo Pharmaceuticals, Inc, Chadds Ford, Pa.), a local anesthetic that blocks sodium channels. This product was recently approved by the Food and Drug Administration for the treatment of postherpetic neuralgia. The lidocaine patch reduces peripheral nociceptor sensitization and diminishes central nervous system excitability, making it a suitable option for offlabel use in the treatment of chronic neuropathic pain.7 In terms of safety, insignificant lidocaine serum levels are achieved, even with chronic use. Because it is an amide-type anesthetic, lidocaine has a lower incidence of allergic reactions than the ester-type anesthetics, such as procaine and tetracaine.7
A eutectic mixture of local anesthetics, consisting of lidocaine 2.5% and prilocaine 2.5% (EMLA cream; AstraZeneca, Wilmington, Del.) is a viable alternative for local analgesia. In a meta-analysis of clinical trials of pain associated with chronic venous ulcers,8 EMLA was found to be statistically significant in reducing debridement pain scores. Because local anesthetics might have a vasoactive effect in addition to producing analgesia, a small, prospective, placebo-controlled study9 attempted to document the effect of EMLA 5% cream on cutaneous circulation. Using video capillaroscopy, laser Doppler flowmetry, and skin temperature, cutaneous circulation was continuously monitored under standardized conditions. The results showed that EMLA cream upregulated nutritive perfusion. No clinically relevant vasoconstrictive effects are expected from an application period of 60 minutes. Further research is warranted to determine the impact of EMLA on wound healing.
Koleshikov et al10 found consistent anesthetic synergy between a topical opioid and a local anesthetic agent. The combination of low doses of local morphine and lidocaine revealed activity far beyond additive interactions, strongly suggesting synergy between opioids and lidocaine. This fact could provide further insight into the use of topical agents in managing pain in chronic wounds.
Amitriptyline, a tricyclic antidepressant, has potent local anesthetic properties. Haderer et al11 reported that transdermally applied amitriptyline is more potent than lidocaine in providing cutaneous analgesia in rats. Each test group developed a concentration-dependent cutaneous analgesic block in the areas to which the drugs were applied; however, amitriptyline produced a longer block than lidocaine at the same concentration with an occlusive dressing. The development of amitriptyline as a longer-lasting topical analgesic may improve the ability to treat chronic pain, such as neuropathic pain.
Briggs et al12 have proposed several non-medicinal methods to reduce a patient’s apprehension at dressing removal:
• identify what the patient recognizes as pain triggers and as pain-alleviating factors
• involve the patient in the dressing change if possible, including allowing the patient to remove the dressing himself or herself
• encourage slow, rhythmic breathing during the procedure
• offer the patient the option to call a “time-out” during the procedure.
In a recent large-scale study,13 the European Wound Management Association found that the most important strategy for avoiding wound damage, and hence anticipatory distress, was the use of nontraumatic dressings. According to recent trends in wound care, dressing choice should be reconsidered if soaking is required for removal or if removal is causing a problem with pain or bleeding/trauma. Dressings that were identified as the least likely to cause trauma were hydrofibers, hydrogels, alginates, and soft silicones. Interestingly, the survey found that the most important factors influencing the clinician’s choice of dressings were financial and reimbursement issues, not the likelihood of reducing pain.
Pain in pressure ulcers can be persistent, permanent, or episodic (occurring at dressing changes and/or debridement). Management of this pain goes beyond administering a set dosage of a prescribed analgesic. Objective pain assessment should be done not only during dressing changes, but also before and after the procedure for an integrative evaluation of the patient’s distress.
Addressing the Pain is made possible through the support of Mölnlycke Health Care, Newtown, PA.
This article was excerpted from Popescu A, Sal Salcido R. Wound pain: a challenge for the patient and the wound care specialist. Advances in Skin & Wound Care: The Journal for Prevention and Healing. 2004;17(1):14-20. Used with permission.
1. Parsons CG, Czlonkowki A, Stein C, et al. Peripheral opioid receptors mediating antinociception in inflammation. Activation by endogenous opioids and role of the pituitary-adrenal axis. Pain. 1990;41:81-93.
2. Hassan AHS, Ableitner A, Stein C, et al. Inflammation of the rat paw enhances axonal transport of opioid receptors in the sciatic nerve and increases their density in the inflamed tissue. Neurosci. 1993; 55:185-95.
3. Stein C. Peripheral mechanism of opioid analgesia. Anesth Analg. 1993;76:182-191.
4. Stein C, Hassan AHS, Lehrberger K, et al. Local analgesic effect of endogenous opioid peptides. Lancet. 1993; 342:321-324.
5. Vande Berg JS, Rudolph R. Pressure (decubitus) ulcer: variation in histopathology — a light and electron microscope study. Hum Pathol. 1995;26:195-200.
6. Flock P. Pilot study to determine the effectiveness of diamorphine gel to control pressure ulcer pain. J Pain Symptom Manage. 2003; 25:547-554.
7. Argoff CE. New analgesics for neuropathic pain: the lidocaine patch. Clin J Pain. 2000;16(2 suppl):S62–S6.
8. Cochrane Database Syst Rev. 2003;(1):CD001177.
9. Hafner HM, Thomma SR, Eichner M, Steins A, Junger M. The influence of EMLA cream on cutaneous microcirculation. Clin Hemorheol Microcirc. 2003;28:121-128.
10. Kolesnikov A, Chereshnev I, Pasternak GW. Analgesic synergy between topical lidocaine and topical opioids. J Pharmacol Exp Ther. 2000; 295:546-51.
11. Haderer A, Gerner P, Kao G, Srinivasa V, Wang GK. Cutaneous analgesia after transdermal application of amitriptyline versus lidocaine in rats. Anesth Analg. 2003;96:1707-1710.
12. Briggs M, Torra JE, Bou I. Pain at wound dressing changes: a guide to management. In: Pain at Wound Dressing Changes, European Wound Management Association Position Document, Spring 2002. Available at http://www.Tendra.com/Files/ Tendra/safetac/ENGLISH.pdf. Accessed December 16, 2003.
13. Moffatt CJ, Franks PJ, Hollinworth H. Understanding wound pain and trauma: an international perspective. In: Pain at Wound Dressing Changes, European Wound Management Association Position Document. Spring 2002. Available at: http://www.Tendra.com/Files/Tendra/safetac/ENGLISH.pdf. Accessed December 16, 2003.
