Pain: Is It All In Your Head? Pain: Is It All In Your Head?

International Myeloma FoundationPatient and Family Seminar May 14, 2005

Maureen A. Carling RN SCM, NDN, HV, FET (England)

© 2000 Maureen A. Carling All Rights Reserved

The Tragedy of Needless The Tragedy of Needless Pain.Pain.

Despite the fact that most pain can be managed effectively, the under-treatment, inappropriate treatment, and in some cases, failure to treat at all, is common.

Do not accept poor pain management

Pain and InvalidationPain and Invalidation

“Its all in your head.”

“You’ll just have to learn to live with the pain.”

“You have a low threshold for pain.”

Pain and InvalidationPain and Invalidation

If you hurt, then you DO have pain.

Do not allow others to invalidate you.

Keys to Effective Pain Keys to Effective Pain ManagementManagement

Assessment – to identify the TYPES of pain being experienced.

(See Carling Algorithm and Pain assessment Sheet)

1/3 patients have four pains or more.

Not all pain responds to opioids (narcotics)

Assessment Assessment

Before medications are prescribed, we need to know which types of pain you are experiencing, so that the appropriate medications can be prescribed.

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Assessment of PainEffective pain control depends on the identification of the different TYPES of pain and the careful TITRATION and APPROPRIATE medication against EACH pain. Therefore a full and detailed assessment is the linchpin on which treatment depends. It should be remembered that 1/3of patients have 4 pains or more and not all pains are opioidresponsive. Assessment of pain identifies the CAUSES of pain. Level and intensity is a measure of the EFFECTIVENESS OF MEDICATION. Therefore level and intensity of pain, while being of value, if estimated at the beginning of assessment may lead the practitioner to seek an increase in the existing medication, which may or may not be appropriate.

Date _________ Signature of Assessor ________________________________ M.A.Carling, 1995

A. Do You have any pain? Yes/No________________

B. Location of pain(s) - Use body chart to map and number each site of pain

C. Quality of each pain and state if continuous or

intermittent (Quote patient’s own words)

1.___________________________________________2.___________________________________________3.___________________________________________4.___________________________________________5.___________________________________________6.___________________________________________7.___________________________________________8.___________________________________________

D. Present Pain Medication

1.___________________________________________2.___________________________________________3.___________________________________________4.___________________________________________5.___________________________________________

E. Assess the effectiveness of each medication against each pain. e.g. “When you take your _____ tablet, does it completely relieve your pain,just ease it a little, or does it not touch the pain at all?

F. What makes the pain better? __________________

G. What makes the pain worse? __________________

Keys to Effective Pain Keys to Effective Pain ManagementManagement

Titration – adjusting the dosage of medication, which can mean an increase or a decrease, to achieve pain relief with the minimum or no side effects.

TitrationTitration

Once medications are prescribed, the dosage has to be adjusted until pain is under control.

If you have three types of pain, then you may need three types of medications , which will need to be adjusted individually until each pain is brought under control.

TitrationTitration

Some medications, such as opioids (morphine, oxycodone etc,), can be titrated fairly quickly.

Others such as antidepressants and anticonvulsants may take several weeks to titrate.

TitrationTitration

You need to be able to differentiate between the different types of pain so you will know which medication to take.

Frequent and Regular Frequent and Regular MonitoringMonitoring

Pain is dynamic – it increases, it decreases and it changes in nature. Your medications may need to be adjusted accordingly.

Titration and the Therapeutic Titration and the Therapeutic WindowWindow

Pain should be ‘controlled’ rather than treated.

Long acting opioids can control the same level of pain by as much as one third less dosage.

It is false economy to wait until you have pain before you take the medication and you are suffering needlessly.

The Therapeutic WindowThe Therapeutic Window

Titration and the Therapeutic Titration and the Therapeutic WindowWindow

Aim of titration is to obtain and maintain level which lies inside the therapeutic window.

When level rises above upper parameter, you will begin to feel ‘hung-over.’

When level falls below lower parameter, you will experience ‘breakthrough pain.’

Titration and the Therapeutic Titration and the Therapeutic WindowWindow

Statistically, if the pain breaks through, it takes 25%-30% of the SAME drug in immediate release form, to raise the level back inside the window.

If the pain breaks through 2-3 times per day or more, it suggests that the level of the long acting drug is at the lower margin of the window.

““Rule of Thumb”Rule of Thumb”

If the pain breaks through 2-3 times per day or more, it is an indication that the level is in the lower margin of the window and the 12 hour dosage needs to be increased by 50%, with a corresponding increase in the breakthrough dosage to represent 1/3 of the NEW dosage.

““Rule of Thumb”Rule of Thumb”

Conversely, if your pain comes down, eg after radiation therapy, then the medications

will need to be reduced. If you wake up feeling ‘hung-over,’ especially if there has been no breakthrough pain the previous day or so, then this is an indication that your pain has come down..

The 12 hour dosage is reduced by 1/3 with a corresponding decrease in the breakthrough medication to represent 1/3of the NEW dosage.

Rule of ThumbRule of Thumb

Do not take breakthrough medication routinely every four hours to prevent pain. The long acting drug is for that.

Keep your medication regimen simple. Take your medication with your breakfast and supper and then you are free for the day, to get on with your life. Just take your ‘rescue’ dose with you in case you need it.

Side effectsSide effects

Remember, there are side effects to pain as well as side effects of medication.

Side effectsSide effects

Constipation in EVERYONE taking opioids.

You need a ‘pusher’ eg Senokot and a stool softener from the first dose of an opioid. Opioids slow the bowel down. Your ‘pusher’ speeds it up again. It puts the ‘push’ back that the opioid has taken out.

Take it EVERY day.

Side EffectsSide Effects

Nausea and vomiting. If this occurs, it is usually for the first 48 hours after starting on an opioid for the first time. Taking an anti-emetic with the opioid for the first couple of days can prevent this.

The commonest cause of nausea and vomiting after this time, is poor bowel management. Prevent it happening in the first place by taking your ‘pusher’ and softener regularly

Calling for HelpCalling for Help

Call your doctor or nurses:

If the medication you are taking is not controlling your pain.

If you have breakthrough pain 2-3 times daily or more.

Calling for HelpCalling for Help

If you wake up feeling ‘hung-over’ and especially, if you have had no breakthrough pain the previous day or so.

If you have not had your bowels moved for three days or more.

Calling for HelpCalling for Help

If you have nausea and /or vomiting

If you develop new pains.

New Approaches for New Approaches for Controlling Neuropathic PainControlling Neuropathic Pain

Neuropathic pain can be controlled using antidepressants and/or anticonvulsants, which need to be titrated up slowly over several weeks.

These are now available in topical form along with other drugs such as Guaifenesin, Clonidine, Ketamine, NSAIDs and other drugs.

New Approaches to New Approaches to Controlling Neuropathic PainControlling Neuropathic Pain

Advantages:Reduce side effects considerably.

Relief is faster on considerably lower dosages.

A Compounding Pharmacist would help you with this.

Body Map Showing Body Map Showing DermatomesDermatomes

Pain CAN and SHOULD be controlled

You have nothing to fear, but fear itself