Since 1971, patients have been using authorized agent-controlled analgesia (AACA) to maximize pain treatment, with the first commercially marketed AACA pump emerging in 1976. AACA’s objective is to efficiently give pain relief at a patient’s desired dose and schedule by enabling them to give a set bolus dosage of medicine on-demand with the push of a button. Each bolus can be provided alone or in conjunction with a continuous drug infusion. Agent-controlled analgesia is used to manage acute and chronic pain, and postoperative and labor pain. These drugs can be injected intravenously, epidurally, or transdermally using a peripheral nerve catheter. Opioids and local anesthetics are frequently used; however, dissociative agents or other analgesics may also be used. Agent-controlled analgesia more successful than nonpatient opioid injections at controlling pain and to result in improved patient satisfaction.¹

Nurses are responsible for peripheral intravenous line installation, ACAA pump setup, medicine injection into the pumps, and monitoring of the patient’s pain, sedation, and breathing. They verify that the pump is operating properly and that the drugs are being administered in the most effective manner possible while preventing difficulties and minimizing adverse effects.

While ACAA can alleviate the requirement for rounding and responding to patient demands for analgesic administration, it does not alleviate their burden; this is due to the time and effort required to educate the patient, set up the machine, and evaluate its effectiveness and adverse effects. However, it has been demonstrated that this is the preferred way since nurses and patients alike have greater control over their job and suffering.¹

Authorized agent-controlled analgesia may be an option for individuals with acute, chronic, postoperative, or labor pain, particularly those who are unable to accept oral drugs. AACA can be utilized to alleviate the strain on nursing staff and patients associated with adhering to a set dose schedule of as-needed analgesics that may not effectively correspond to the patient’s fluctuating pain. AACA may be beneficial in the acute pain context when the first opioid dose administered in the emergency room is insufficient to manage pain, and continuous opioid dosage has been shown to enhance patient outcomes. Vasoocclusive pain crises, trauma, pancreatitis, and burns are all common instances. AACA would be used in conjunction with other therapies to alleviate pain while the underlying cause is identified and addressed. Patients with
chronic conditions who have less consistent chronic pain may potentially benefit from AACA. Metastatic malignancy, phantom limb syndrome, and complicated regional pain syndrome are the most prevalent instances. AACA is also an excellent option for postsurgical patients, particularly those with indwelling nerve or epidural catheters. The capacity of a postoperative patient to titrate and give their own pain medication enables greater pain management compared to scheduled nurse doses. Additionally, it improves patient satisfaction and reduces the need for PACU and acute pain treatment staff intervention. Patients experiencing labor discomfort are also well-suited for epidural AACA. Contracture pain, which is worsened by induction drugs such as oxytocin, can be sufficiently minimized and regulated by the patient.¹ Contraindications are listed in Table 48.1.

There are many aspects to the concept of ACAA and, by extension, AACA (Fig. 48.1). However, ethical and legal considerations have become prevalent due to cases where the patient self-administering the medication is too young to comprehend the action or the patient without the capacity to self-administer the medication.² In many states, family nurse practitioners have “prescriptive authority,” and the intent of treatment along with who is authorized to administer the treatment must be clearly defined.³ The authorization of who will administer the treatment to the patient must be determined to minimize any unintentional risk to the patient. Administration methods include the patient themselves (patient-controlled analgesia or ACAA), authorized agent-controlled analgesia (an authorized caregiver or health care worker who has been educated in the risks and methods), or if the drugs are administered by someone not informed on the risks and methods (“ACAA by proxy”). “ACAA by proxy” is not supported by the American Society for Pain Management Nursing (ASPMN), as it is unsafe and increases the risk of harm to the patient.² For drug administration to be considered AACA and not “ACAA by proxy,” the responsibility of education lies on nursing staff to “authorize” and educate caregivers of the methods and risks of drug administration.⁴ The ASPMN determines that AACA is an acceptable option for the relief of pain. AACA is an umbrella term that encompasses both nurse-controlled analgesia and caregiver-controlled analgesia. While the benefits of AACA/ACAA are clear (such as patient autonomy, lower health care cost, and a decreased hospital stay), the candidate must be chosen appropriately to mitigate any risks to the patient.¹,³ AACA has been proven to be safe and effective method for pain management in patients from children to adults.² Candidates for ACAA and those who will be involved in AACA must understand the relationship between pain, pressing (activating) the analgesic delivery, and be clear on the goal of pain relief.² Additionally, drugs should be carefully
considered, such as considering antiemetics or adding long-acting local anesthetics in combination with opioids.⁴ The risk of including opioids is not just the physical manifestation (respiratory depression) but also must be viewed through the scope of the opioid crisis.⁴ Therefore, researchers are currently evaluating nonopioid drug options to use in AACA and ACAA, but currently, opioids are still in use in decreased quantities or in combination with nonopioid analgesics.⁴ As AACA and ACAA positively impact patient satisfaction, opioids are preferred due to the time of onset.⁴