Pain Management
What is it?
Dr Ibraheem Bashayreh, RN, PhD
21/10/2009
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Pain…
What is the real definition of pain?
And what is pain management??
How can this information help me???
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Pain
Definitions:
An unpleasant sensory and emotional experience
associated with actual or potential tissue damage.
Pain is whatever the experiencing person says it is.
May not be directly proportional to amount of tissue
injury.
Highly subjective, leading to undertreatment
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Classification of Pain
• 1. Acute
• 2. Cancer
• 3. Chronic non-malignant
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Acute Pain
• Injury, trauma, spasm or disease to skin, muscle, somatic
structures or viscera;
• Perceived and communicated via peripheral mechanisms
(pathways) A delta and C fibers
• Usually with autonomic response as well (tachycardia,
blood pressure, diaphoresis, pallor, mydriasis (pupil
dilation);
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Acute Pain
• Usually subsides quickly as pain producing stimuli
decreases
• Associated with anxiety-(decreases rapidly)
• Can be understood or rationalized as part of the
healing process.
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Chronic Pain
•
•
•
•
Non-malignant
Pain persists beyond the precipitating injury
Rarely accompanied by autonomic symptoms
Sufferers often fail to demonstrate objective evidence of
underlying pathology.
• Characterized by location-visceral, myofacial, or
neurologic causes.
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Chronic Pain
• Malignant
• Has characteristics of chronic pain as well as
symptoms of acute pain (breakthrough pain).
• Has a definable cause, e.g. tumor recurrence
• In treatment, narcotic habituation is generally not
a concern.
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Types of Pain
•
•
•
•
•
•
Somatic
Visceral
Referred
Bone
Neuropathic
Emotional/Spiritual
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Somatic Pain
• Aching, often constant
• May be dull or sharp
• Often worse with movement
• Well localized
• Skin, Muscle, Joints, superficial
or deep.
Eg:
– Bone & soft tissue
– chest wall
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Visceral Pain
•
•
•
•
•
Constant or crampy
Aching, burning
Poorly localized
Referred
Organs of Thorax & Abdominal
Cavity. Usually as a result of
stretching, infiltration and
compression
Eg/
– CA pancreas
– Liver capsule distension
–21/10/2009
Bowel obstruction
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Types of Pain
•Both Somatic & Visceral pain travel along
the same pathways. Pain stimuli arising from
the viscera is perceived as somatic in origin.
This can be confused by the brain and is often
described as referred pain.
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Liver
Liver
Heart
Stomach
Gallbladder
Small Intestine
Appendix
Right Ureter
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Ovary
Colon
Kidney
Bladder
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Types of Pain
• Bone Pain
• Poorly localised, aching, deep, burning.
• Common with Breast, Lung, Prostate,
Bladder, Cervical, Renal, Colon, Stomach
and Oesophagus
• Can lead to pathological fractures.
• Vertebral Metastases can lead to cord
compression.
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Bone Pain
• Osteoblasts, Osteoclasts and Osteocytes are
involved in remodelling bone.
• In healthy individuals bone remodelling is
carefully regulated.
• Normally Osteoblasts replace the same
amount of bone which has been resorbed by
the Osteoclasts.
• In malignancy process not balanced,
resulting in a loss of bone mass.
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Types of Pain
• Neuropathic Pain
• Caused by disturbance of function or
pathological changes in a nerve.
• May arise from a lesion or trauma,
infection, compression or tumour invasion.
• Described as burning, shooting, tingling.
• Does not respond well to standard
analgesics.
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Neuropathic Pain
• Abnormal Sensations
• Hyperaesthesia - an increased sensitivity to
stimulation.
• Hyperalgesia – increased response to a
stimulus that is normally painful.
• Allodynia – pain caused by a stimuli that is
not normally painful
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Neuralgia
Pain in the distribution of the nerve,
lancing, shooting, jumping, electricity.
Parasthesia
An abnormal sensation, tingling, pins and
needles.
Tight Feeling
Vice like tightness, gripping, cramping.
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Major Categories of Pain
Classified by inferred pathophysiology:
1. Nociceptive pain (stimuli from somatic
and visceral structures)
2. Neuropathic pain (stimuli abnormally
processed by the nervous system)
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Effects of pain
Sympathetic responses
• Pallor
• Increased blood pressure
• Increased pulse
• Increased respiration
• Skeletal muscle tension
• Diaphoresis
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Effects of pain
Parasympathetic responses
• Decreased blood pressure
• Decreased pulse
• Nausea & vomiting
• Weakness
• Pallor
• Loss of consciousness
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FACTORS INFLUENCING
PAIN
•
•
•
•
•
PHYSIOLOGICAL
SOCIAL
SPIRITUAL
PSYCHOLOGICAL
CULTURAL
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Pain Assessment
• Pain History
The site of pain
Type of pain
Exacerbating & Relieving factors
How frequently
Impact on daily life
Previous therapies
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Pain Assessment
•Factors to Consider
Mood
Non Verbal Communication
Environment
Ethnicity
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BOX 8-2 (continued) ASSESSMENT
Concerns & Misconceptions
• Pain is inevitable.
• If the pain is worse, my cancer is spreading.
• I should wait until I really need my pain
killer, before I take it.
• If I take Morphine I will die soon.
• I will get addicted to pain killers.
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PAIN ASSESSMENT Tools
• PAIN RATING
SCALES- NRS,
VAS,VAT,FACES
RATING SCALE,
• PAIN-0-METER
• McGill PAIN
QUESTIONNAIRE
• BODY MAP
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Severity Assessment
McGill Pain Questionnaire
• 0 ----------> 5
• None -------------------> Excruciating
• Mild, Discomforting, Distressing, Horrible, in
between.
• (for children or adults who understand numerical
relationships)
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ABCDE for pain assessment
&management
• Ask about pain regularly
• Believe the patient and family in their
reports &what relieves it
• Choose pain control options appropriate
for the patient
• Deliver interventions timely, logical
&coordinated fashion
• Empower patient and their families
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JCAHO Standards for postoperative pain
management are:
• Recognize patients’ rights to appropriate
assessment and management of pain
• Screen for pain and assess the nature and
intensity of pain in all patients
• Record assessment results in a way that allows
regular reassessment and follow-up
• Determine and ensure that staff are competent in
assessing and managing pain.
• Address pain assessment and management when
orienting new clinical staff
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Standards Contd..
• Establish policies and procedures that
support appropriate prescribing of pain
medications
• Ensure that pain doesn’t interfere with a
patient’s participation in rehabilitation
• Educate patients and their families about
effective pain management
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Pain
Treatment
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WHO Pain Management Ladder
3
By the
Strong opioid
+/- adjuvant
2
Clock, Mouth Weak opioid
+/- adjuvant
1
Non-opioid
+/- adjuvant
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WHO Pain Management Ladder
Step 3
Step 2
Step 1
NSAIDS,
+ adjuvants
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NSAID
+ mild
opioids
+ adjuvant
strong
opioids +
NSAIDS
+ adjuvants
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VAS vs WHO
VAS
1-3
4-6
7 - 10
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WHO Steps
Step 1
Step 2
Step 3
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Analgesics
Non-opioid
Opioid
e.g. aspirin,
paracetamol
e.g. codeine,
morphine
Adjuvant
e.g. muscle relaxant,
antidepressant,
anti-epileptic
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Opioid Side Effects
• Constipation – need proactive laxative use
• Nausea/vomiting – consider treating with
dopamine antagonists and/or prokinetics
(metoclopramide, domperidone,
prochlorperazine [Stemetil], haloperidol)
• Urinary retention
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Opioid Side Effects
• Itch/rash – worse in children; may need low-dose
naloxone infusion. May try antihistamines, however not
great success
• Dry mouth
• Respiratory depression – uncommon when titrated
in response to symptom
• Drug interactions
• Neurotoxicity (OIN):
delirium, myoclonus 
seizures.
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Management contd..
Non-pharmacological
interventions
• Massage
• Diversion therapy
• Relaxation therapy
• Heat & cold
applications
• Yoga
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Summary
• Pain is a subjective experience and is
influenced by many factors not just physical
processes
• The WHO pain ladder is recommended
• Introduce drug therapy in stepwise manner,
matching the initial analgesic to the level
and type of pain
• Other interventions, drug and non drug
should be considered
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“Pain is a more terrible lord of mankind than
death itself.”
Albert Schweitzer
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When the music changes, so must the
dance….
African Proverb
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