ESSENTIAL PAIN MANAGEMENT

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EPM Aims

1.To improve understanding of pain2.To teach a simple framework for managing

pain3.To reduce pain management barriers

1.2

Workshop Plan 1

• Pain basics– What is pain?– Why should we treat pain?– Classification of pain– Physiology and pathology– Pain treatment– Barriers to treatment

1.3

Workshop Plan 2

• Practical pain management– Case discussions– Overcoming barriers

1.4

Untreated Pain

1.5

Untreated Pain

• Often hidden (not recognized)• Causes a lot of suffering• But … can often be treated simply and cheaply

1.6

Approach to Pain

• Recognize• Assess• Treat

1.7

Approach to PainR

• Recognize– Does the patient have pain?– Do other people know the patient has pain?

1.8

Approach to PainA

• Assess– How severe is the pain?– What type of pain is it?– Are there other factors?

1.9

Approach to PainT

• Treat– What non-drug treatments can I use?– What drug treatments can I use?

1.10

?1.11

IntroductionSummary

• At the end of this course, you will be able to:

1. Understand the importance of treating pain2. Recognize, assess and treat different types of

pain3. Identify and address barriers where you work

1.12

What is Pain?

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What is Pain?Aims

• To define pain• To give examples of pain

2.2

What is Pain?

• Group discussion

– Think of a patient / friend / relative who had pain.– How did the person describe the pain?– How was it treated?

2.3

What is Pain?

• International Association for the Study of Pain– Pain is "an unpleasant sensory and emotional

experience associated with actual or potential tissue damage, or described in terms of such damage”.

• What does this mean?• Are there any other definitions?

2.4

What is Pain?

• Unpleasant• Emotions are important• The cause is not always visible

• “Pain is what the patient says hurts.”

2.5

Is this man feeling pain?2.6

?2.7

What is Pain?Summary

• Pain is an unpleasant sensory and emotional experience

• Pain is what the patient says hurts!

2.8

Why Should We Treat Pain?

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Why Should We Treat Pain?Aims

• To understand the reasons for treating pain• To understand the benefits for the patient,

family and society

3.2

Case 1

• Mr T is a 29-year-old man with a fast growing mouth cancer that has spread to his bones. He has severe face pain. He is expected to die within 6 months and the surgeons do not want to operate. He is married with two children, aged 11 and 8

• Why should we treat his pain?

3.3

Case 2

• Mrs G is a 54-year-old woman who has just had a laparotomy for bowel obstruction. You see her on the surgical ward soon after the operation. She appears to be in pain.

• Why should we treat her pain?

3.4

Why Pain Matters

• For the patient– Physical • Suffering, poor sleep, decreased appetite• Medical complications

(e.g. heart attack, pneumonia)– Psychological• Depression, anxiety

3.5

Why Pain Matters

• For the family– Unable to function as part of the family

(e.g. as a father / mother)– Lost income

• For society– Greater health costs

(e.g. delayed hospital discharge)– Unable to contribute to the community

3.6

Painful SCC (xeroderma pigmentosum)

3.7

Advantages of Treating Pain

• For the patient– Fewer physical and psychological problems– Greater dignity (esp. cancer pain)

• For the family– Able to function as part of the family– Able to provide for family

• For society– Lower health costs

3.8

?3.9

Why Should We Treat Pain?Summary

• Treating pain is the “humane” thing to do!• Treating pain has many benefits– For the patient– For the family– For society

3.10

Classification of Pain

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Classification of PainAims

• To classify types of pain• To understand that treatment depends on the

pain type

4.2

Classification of Pain

• Not all pain is the same!• Three main questions:

1. How long has the patient had pain?2. What is the cause?3. What is the pain mechanism?

4.3

Classification of Pain

Duration AcuteChronicAcute on chronic

Cause CancerNon-cancer

Mechanism Nociceptive (physiological)Neuropathic (pathological)

4.4

Acute versus Chronic

• Acute– Pain of recent onset and probable limited

duration

• Chronic– Pain persisting beyond healing of injury– Often no identifiable cause– (Pain lasting for more than 3 months)

4.5

Cancer versus Non-Cancer

• Cancer pain– Progressive– May be mixture of acute and chronic

• Non-cancer pain– Many different causes– Acute or chronic

Can you give examples?

4.6

Invasive oral cancer

4.7

Nociceptive Pain

• Obvious tissue injury or illness• “Physiological pain”• Description– Sharp ± dull– Well localised

Can you give examples?

4.8

Neuropathic Pain

• Nervous system damage or abnormality• “Pathological pain”• Tissue injury may not be obvious• Description– Burning, shooting ± numbness, pins and needles– Not well localised

Can you give examples?

4.9

Examples of Pain Types

4.10

Acute Non-Cancer Pain

• Examples– Fracture, appendicitis

• Symptom of tissue injury or illness• Useful• Usually nociceptive• Occasionally neuropathic (e.g. sciatica)

4.11

Chronic Non-Cancer Pain

• Examples– Headache, back pain

• Usually no obvious injury• Not useful• Complex, may be mixed nociceptive and

neuropathic• Does not respond to usual drug treatment

4.12

Cancer Pain

• Examples– Oral cancer, uterine cervical cancer

• Features of acute and chronic pain– May be acute on chronic

• Often mixed nociceptive and neuropathic pain• Usually gets worse over time if untreated

4.13

?4.14

Classification of PainSummary

• Deciding on the type of pain is important– Acute / chronic– Cancer / non-cancer– Nociceptive / neuropathic

• Treatment depends on the pain type

4.15

Pain Physiology and Pathology

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Pain Physiology and PathologyAims

• To understand normal pain physiology– Pain pathway – Factors affecting the pain signal

• To understand the basis of neuropathic pain(pathology)

5.2

Nociception and Pain

• Nociception– How pain signals get from the site of injury to the

brain

• Pain perception– How we “feel” pain

• Nociception is not the same as pain!

5.3

Is this man feeling pain?5.4

PainWhat the patient says hurts.

What must be treated.

Injury

Beliefs/concerns about pain

Psychol. factorsanxiety/anger/depression

Cultural issuesLanguage, expectations

Other illnesses

Coping strategies

Social factorse.g. family, work

Nociception is not the same as pain!

Modified from Analgesic Expert Group. Therapeutic Guidelines 20075.5

Physiology

• 4 steps:– Periphery– Spinal cord– Brain– Modulation

• We will look at each step

5.6

Periphery

• Tissue injury• Release of chemicals• Stimulation of pain

receptors (nociceptors)

• Signal travels in Aδ or C nerve to spinal cord

5.7

Spinal Cord

• Dorsal horn is the “first relay station”

• Aδ or C nerve synapses (connects) with second nerve

• Second nerve travels up opposite side of spinal cord

5.8

Brain• Thalamus is the

“second relay station”

• Connections to many parts of the brain– Cortex– Limbic system– Brainstem

• Pain perception occurs in the cortex

5.9

Modulation

• Descending pathway from brain to dorsal horn

• Usually decreases pain signal

5.10

Why is pain physiology important?

• Many factors affect how we “feel” pain.– Psychological factors are very important.

• Different treatments work on different parts of the pathway.– More than one treatment may be needed.

5.11

Neuropathic Pain

• “Pathological” pain• Abnormality of:– Peripheral nerves– Spinal cord or brain

• Needs to be treated differently

5.12

Neuropathic Pain

• Peripheral– Damaged nerves (e.g. trauma, diabetes)– Abnormal firing of nerves

• Central– Changes in “wiring”– Abnormal firing– Loss of modulation

How do patients describe their pain?

5.13

?5.14

Pain Physiology and PathologySummary

• Many factors affect how we “feel” pain.• Different treatments work on different parts

of the pain pathway.• Neuropathic pain is “pathological” pain and

needs to be treated differently.

5.15

Pain Treatment Overview

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Pain Treatment OverviewAims

• To discuss non-drug and drug treatments where you work

• To classify pain treatments

6.2

Pain Treatment

• Group discussion

– What non-drug treatments are available where you work?

– What drug treatments are available where you work?

6.3

Non-Drug Treatments

• Physical– Rest, ice, compression, elevation– Surgery– Acupuncture, massage, physiotherapy

• Psychological– Explanation– Reassurance– Counseling

6.4

Placebo Treatment

• Group discussion

– What is placebo?– Is it helpful or unhelpful?

6.5

Placebo Treatment

• Psychological factors are important.• If a placebo treatment works, this does not

mean the patient did not have pain or was telling lies!

6.6

Drug Classification

• Simple analgesics– Paracetamol (acetaminophen)– Anti-inflammatory medicines– Aspirin, ibuprofen

• Opioids– Mild– Codeine

– Strong–Morphine, pethidine

6.7

Drug Classification

• Other analgesics– Amitriptyline– Carbamazepine– Local anaesthetics– Ketamine– Tramadol– Clonidine– Entonox (N2O/O2)

6.8

Treatments - Periphery

• Non-drug treatments– Rest, ice,

compression, elevation

• Anti-inflammatory medicines

• Local anaesthetics

6.9

Treatments - Spinal Cord

• Non-drug treatments– Acupuncture,

massage

• Local anaesthetics• Opioids• Ketamine

6.10

Treatments - Brain

• Non-drug treatments– Psychological

• Drug treatments– Paracetamol– Opioids– Amitriptyline– Clonidine

6.11

?6.12

Pain Treatment OverviewSummary

• Both non-drug and drug treatments are important.

• Different treatments work on different parts of the pain pathway.

• Analgesics can be classified into simple analgesics, opioids and other drugs.

6.13

Pain Drugs

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Pain DrugsAims

• To summarise the major advantages and disadvantages of important drugs

• To discuss drug addiction

7.2

Paracetamol (Acetaminophen)

• Advantages– Cheap, safe– Can be given orally or rectally– Good for:• Mild pain (by itself)• Mod-severe pain (with other drugs)

• Disadvantages– Liver damage in overdose

7.3

Anti-Inflammatory Medicines

• Aspirin, ibuprofen• Advantages– Cheap, generally safe– Good for nociceptive pain• Best given regularly with paracetamol

• Disadvantages– Gastrointestinal and renal side effects

7.4

Codeine

• Advantages– Cheap, safe– Good for mild-moderate acute nociceptive pain• Best given regularly with paracetamol

• Disadvantages– Constipation– Not good for chronic pain– Myths about addiction

7.5

Opioids and Addiction

• Group discussion

– Do opioids cause addiction?– Would this stop you giving opioids to a patient

who has pain?

7.6

Opioids and Addiction

• Pain is sometimes poorly treated because of concerns about addiction.

• Addiction is very rare in:– Acute pain– Cancer pain

• Addiction is more likely in chronic non-cancer pain.

7.7

Morphine 1

• Advantages– Cheap, generally safe– Can be given orally, IV, IM, SC– Effective if given regularly– Good for:• Mod-severe acute nociceptive pain (e.g. post-op pain)• Chronic cancer pain

7.8

Morphine 2

• Disadvantages– Constipation– Respiratory depression in high dose– Myths about addiction– Regulations about use

7.9

Pethidine

• Advantages– Cheap– Can be given orally, IV, IM– Can be good for severe acute nociceptive pain

• Disadvantages– Must be given more often than morphine– Breakdown product (norpethidine) can cause

convulsions– Not good for chronic pain

7.10

Amitriptyline• Increases descending inhibitory signals• Advantages– Cheap, safe in low dose– Good for neuropathic pain– Also treats depression, poor sleep

• Disadvantages– Anti-cholinergic side effects (glaucoma, urinary

retention)

7.11

Anti-Epileptic Drugs

• Carbamazepine (Tegretol)• Sodium valproate (Epilim)• “Membrane stabilisers”– Reduce abnormal firing of nerves

• Good for neuropathic pain

7.12

Entonox (N2O/O2)

• Advantages– Fast onset / fast offset– Good for:• Labour pains• Short painful procedures (e.g. dressing changes)

• Disadvantages– Need cylinder and mask

7.13

Drug TreatmentsAcute noci mild

Acute nocisevere

Acute neuro

Chronic non-cancer

Chronic cancer

Paracetamol +++ ++ + + +NSAIMs ++ ++ + ± ±Codeine ++ + ±Morphine +++ ++ - +++Amitriptyline - - ++ ++ ++Carbamazepine - - ++ + +

7.14

?7.15

Pain DrugsSummary

• Pain can be treated with relatively cheap and safe drugs.

• Opioid addiction is rare in acute or cancer pain.

7.16

Barriers to Pain Treatment

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Barriers to Pain TreatmentAims

• To understand some of the reasons why pain may not be treated adequately

• To think about some solutions

8.2

Barriers to Pain Treatment

• Group Discussion– Pain is often not treated as well as it could be.

What are some of the reasons for this?• Patients• Drugs• Health workers• System issues

– What are the main barriers where you work?– What can be done about these barriers?

8.3

?8.4

Barriers to Pain TreatmentSummary

• There are many reasons why pain is not treated as well as it could be.

• Important barriers are attitudes, lack of staff and lack of drugs.

• How can YOU overcome these barriers where you work?

8.5

Basic Approach to Pain Management

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Basic ApproachAims

• To give a simple framework for managing patients with pain

• To illustrate the use of this framework for different types of pain

9.2

Approach to Pain

9.3

Approach to Pain

• Recognize• Assess• Treat

9.4

Approach to PainRecognize

• Does the patient have pain?– Ask– Look (frowning, moving easily, sweating?)

• Do other people know the patient has pain?– Other health workers– Patient’s family

9.5

Approach to PainAssess

• Measure the severity– What is the pain score?• At rest• With movement

– How is the pain affecting the patient?• Can the patient move, cough?• Can the patient work?

9.6

Measuring Pain

• Helps guide treatment• Methods– Verbal (e.g. mild, moderate, severe)– Numerical• 0 (no pain) to 10 (worst pain imaginable)

– Visual• Visual Analogue Scale (VAS)• “Faces” pain scale

9.7

Visual Analogue Scale

9.8

Faces Pain Scale

9.9

Approach to PainAssess

• Make a pain diagnosis!– Acute or chronic?– Cancer or non-cancer?– Nociceptive or neuropathic?• Look for neuropathic features:

– Burning or shooting pain– Phantom limb pain– Other features (pins and needles, numbness)

9.10

Approach to PainAssess

• Are there other factors?– Physical factors (other illnesses)– Psychological and social factors• Anger, anxiety, depression• Lack of social supports

9.11

Approach to PainTreat

• Non-Drug Treatments– RICE• Rest, ice, compression, elevation of injuries

– Nursing care– Surgery, acupuncture, massage etc– Psychological• Explanation and reassurance• Input from social worker / pastor

9.12

Approach to PainTreat

• Drug Treatments – Nociceptive Pain– Mild• Paracetamol (± NSAIM)

– Moderate• Paracetamol (± NSAIM) + codeine

– Severe• Paracetamol (± NSAIM) + morphine

9.13

Approach to PainTreat

• Drug Treatments – Neuropathic Pain– Traditional drugs may not be as useful– Use other drugs early• Amitriptyline• Carbamazepine

• Don’t forget non-drug treatments

9.14

Approach to PainExample 1

• Mr D is a 32-year-old man who caught his right hand in a piece of machinery at work and now has a large open wound with several broken bones.

• How would you manage his pain?

9.15

Approach to PainExample 2

• Jon is an 8-year-old boy with probable appendicitis. He is in the Emergency Department and will have to wait several hours for an operation.

• How would you manage his pain?

9.16

Approach to PainExample 3

• Miss B is a 24-year-old woman who has a two year history of severe headache. She was seen at the regional hospital 6 months ago and was told that there was “nothing wrong inside her head” and she was going to have to live with the pain.

• How would you manage her pain?

9.17

Approach to PainExample 4

• Maria is a 12-year-old girl with burns to her chest and abdomen. She needs dressing changes every 2-3 days.

• How would you manage her pain?

9.18

?9.19

Approach to PainSummary

• Recognize• Assess– Measure severity– Make a pain diagnosis– Consider other factors

• Treat– Non-drug treatments– Drug treatments

9.20