Reducing pain in the wound care population not only improves quality of life but can accelerate the physiologic processes of healing.¹ The biochemical response to pain exerts a negative effect on wound healing, possibly due to alterations in cortisol and cytokines like catecholamines.^2,3 Patients that report higher pain scores have been known to exhibit delayed wound healing.⁴ Inadequate pain management can delay the application of appropriate interventions. Patients experiencing pain may not be able to withstand complete surgical debridement. Delayed debridement delays healing time^5-7 and places the patient at risk for negative outcomes including infection, osteomyelitis, hospitalization, and amputation. Inadequate debridement potentiates the inflammatory environment of chronic wounds by the continued presence of necrotic tissue, proteolytic enzymes, and bacterial bioburden including biofilm. Surgical debridement also removes senescent cells preventing the senescence-associated secretory phenotype positive feedback loop that can be prominent in disease states like diabetes.^8,9 Surgical debridement also prepares the wound bed for other advanced interventions including negative pressure wound therapy and cellular and/or tissue-based products. Methods of pain control utilized by wound centers consist of pharmacologic and non-pharmacologic interventions.

Pharmacologic methods

Pharmacologic methods of pain control include opioid analgesics, benzodiazepines, acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and topical anesthetics such as lidocaine. A difficulty commonly encountered in wound centers is the concurrent diagnosis of peripheral arterial disease. This disease state not only decreases tissue perfusion and delays wound healing but can also prevent the delivery of medications to their desired site.¹⁰ Oral and intravenously administered drugs may not reach optimal dosing in the wound bed and surrounding tissues when peripheral arterial disease is present.

In the outpatient environment, opioid and benzodiazepine use is limited due to multiple considerations.^11,12 It is illegal for patients to drive under the influence of these medications, and patients are frequently responsible for transporting themselves to appointments. Many wound care patients are elderly, and recommendations from the BEERS criteria¹³—evidence-based practice recommendations for prescribing in geriatric patients—preclude the use of these medications. Patients who require chronic use of opioids or benzodiazepines may have established pain contracts that limit providers outside of their established pain clinic from prescribing the medications. Clinicians should also consider the possibility of abuse and diversion when prescribing opioids. Opioid prescriptions carry a high risk of abuse.¹⁴ The United States is facing an opioid abuse crisis and hospital providers play an important role in addressing the issue.^14,15 Deaths from prescription opioids have nearly tripled since 2001, and hospital visits for acute opioid poisoning including overdose have increased over 100%.¹⁴ Opioid misuse and dependence is higher than previously thought, and has been found to occur in up to 26% of primary care patients taking opioid medications.^11,14 Misuse of prescription opioids and heroin affects more than 11 million Americans, and in 2016 there were more than 60,000 deaths from overdose.¹⁶ Opioids account for more than half of all drug overdose deaths.¹⁶ Even when used as prescribed, opioid medications can have significant side effects including sweating, pruritus, nausea, constipation, depression, sleepiness, dizziness, respiratory depression, increased risk of falls, and low levels of testosterone.¹⁴ Over time, patients taking opioid medications can develop increased sensitivity to pain, known as opioid-induced hyperalgesia.¹⁷

Pharmacologic methods that avoid the use of opioids and benzodiazepines are preferred. These include topical lidocaine, NSAIDs, and acetaminophen. Acetaminophen is a commonly prescribed first-line agent for many pain conditions including wounds, but is more useful for baseline analgesia. Its use for procedural pain is limited. NSAIDs can be added to pain regimens, and at higher dosages exert anti-inflammatory effects. Like any medication, NSAIDs are not without risk, and their use in wound populations can be limited due to comorbidities that preclude their use including chronic kidney disease, diabetes, and heart disease.¹³

Topical and injectable lidocaine is a standard intervention for control of procedural pain in wound centers due to its safety profile and ability to prevent or limit pain with minimal systemic effects.^10,18-20 Blood flow to the tissue where lidocaine is being used determines the absorption rate and plasma level.¹⁰ Preparations vary and include solutions, creams, and jelly. Lidocaine has a desirable onset time period for wound clinics and can be mixed with prilocaine (EMLA) to extend the length of analgesia. For procedures that may cause bleeding with the potential to interfere with the procedure, lidocaine and epinephrine are injected with the desired effect being local vasoconstriction contributing to hemostasis during the procedure. The safety of lidocaine solution for procedural wound pain has been examined in solutions as high as 10%,¹⁹ but use of 1% to 4% solution is typically satisfactory for relief of procedural pain including surgical debridement and negative pressure wound therapy dressing changes. Possible risks of topical lidocaine include the potential for lidocaine toxicity. Lidocaine toxicity is a rare, usually self-limited condition that may occur if topical lidocaine is inadvertently injected intravascularly and blood levels rise above 5 mcg/mL; symptoms include circumoral numbness, tongue paresthesia, dizziness, tinnitus, blurred vision, restlessness, agitation, nervousness, paranoia, muscle twitches, and seizures.¹⁰ These issues are more commonly encountered in the field of esthetics and pediatrics where patients are administering lidocaine in the home over larger body surface areas or orally, sometimes multiple times per day.²¹

Non-Pharmacologic Methods

Non-pharmacologic methods of pain control for wound centers are preferred and include distraction, prioritization of less innervated areas during surgical debridement, utilization of non-surgical debridement modalities, atraumatic dressing removal techniques, and low-frequency non-contact ultrasound. Clinicians can utilize debridement techniques that prioritize tissue depths and locations with less sensory nerve fibers, such as beginning in the center of the wound where tissue depth is often at its greatest and debriding the wound edge—where pain can be greatest—at the end of the procedure. In this way, if the patient requests cessation of the procedure due to pain, more of the wound bed has been treated. Non-surgical modalities of debridement can be used as either standalone interventions or in concert with surgical debridement. These include micellar surfactants, enzymes, microfiber pads, ultrasound, and dressings to facilitate autolysis. Non-contact low-frequency ultrasound increases perfusion, decreases bioburden, and expedites would healing.²² Through these processes it is also associated with reductions in wound-related pain. Its use can unfortunately be limited by institutional access and insurance approval, but it is an excellent adjunctive therapy when addressing wound pain.

Procedural pain control for wound patients is an important component in the provision of care. Wound specialists should avoid the use of benzodiazepines or opioids and utilize other pharmaceutical and non-pharmaceutical methods of pain control. Providers have multiple modalities to choose from with established safety records when used appropriately in the wound center or bedside environment.

References

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