Pain management

Dr. Riyadh M. Hasan Consultant surgeon

Prevalence
Pain of any type is the most common reason for physician consultation in the United States, prompting half of all Americans to seek medical care annually.

Pain Definition
unpleasant sensory and emotional experience associated with tissue damage (actual or potential). May not be directly proportional to amount of tissue injury. Highly subjective,
leading to undertreatment

Types of Pain
Acute pain: Chronic pain:
involves complex processes and pathology. Usually involves altered anatomy and neural pathways.

Acute Pain
Abrupt, severe, short-lived Acute pain serves to alert after an injury or malfunction of the body Can last from moments to weeks usually stops without treatment or responds to simple measures such as resting or taking an analgesic Caused by injury or trauma

Chronic Pain
Intractable pain that responds poorly to simple measures and interferes with one's ability to participate in physical activity Caused by disease and normal aging May be contributed to a single factor or combination of factors prolonged, last longer than 6 months, and sometimes, for life. Defined as the disease of pain.

Major Categories of Pain

I. II.
1. a.

Nociceptive pain (stimuli from somatic and visceral structures) Neuropathic pain
(abnormal processing of stimuli by the nervous system (peripheral or central) May be caused by:
a. b. c. d. injury (amputation and subsequent phantom limb pain), scar tissue from surgery (back surgery high risk), nerve entrapment (carpal tunnel), damaged nerves (diabetic neuropathy)

Most important Mediators 1. 2. 3. 4. 5. Prostaglandins Bradykinin Serotonin substance P histamine

Pain Important facts

Patients perceive pain as a stressor as the injury itself with same physiological responses Amplifies the bodys stress response to the injury Causes endocrine and metabolic abnormalities Impedes a patients recovery from trauma and surgery

Numeric Rating Scales

Numeric rating scale of 0 (representing no pain) to 10 (representing the most imaginable pain possible) Most common rating scale Not effective in children

Wong Baker FACES Chart

Visual Chart Useful with children and people with language barriers

Populations at high risk

Cognitively impaired Very young, very old Trauma, hemodynamically unstable

Chronic pain syndromes

Poorly controlled acute pain can predispose patients to debilitating chronic pain syndromes (McCaffery & Pasero, 1999). Chronic pain syndromes are often the result of traumatic injury (Muse, 1986).

Effects of Unrelieved Pain

Increased physiologic stress Diminished immunocompetence Reduced mobility Increased risk of pneumonia and thromboemb ibolism Increased work of breathing Increased myocardial oxygen demands Spiritual despair, Depression, Anxiety

Pain can kill

If pain is allowed to be prolonged, it may exhaust the patients physiology death may result

Under Treatment of Pain why??

Not considered a priority
Minimal knowledge base effective interventions by healthcare providers Fear of addiction Fear of misdiagnosis

Undertreated or untreated??
The study of pain is relatively new Lack of knowledge concerning harmful effects of unrelieved pain Personal biases

Pain - a persistent problem

it remains a common misconception amongst clinicians that acute postoperative pain is a transient condition involving physiological nociceptive stimulation, with a variable affective component, that differs markedly in its pathophysiological basis from chronic pain syndromes.
Cousins MJ, Power I, and Smith G. Regional Analgesia and Pain Medicine, 25 (2000) 6-21

General rules
Pain can and should be treated. The right dose is the dose that relieves pain. Physical and psychological approach. Oral route is preferred. Regular intervals for continuous pain. By ladder regimen for the type and dose of the drug.

Pain Management Interventions

Pharmacologic Rehabilitative Behavioral

Categories of analgesia
Analgesic drugs:
NSAID :(paracetol,aspirin,.) Weak opiate:(Codeine,Tramadol,.) Strong opiate:(Morphine,pethidin,..)

Adjuvants
STEROIDS:Decadron,Prednisolon,. Anticonvulsant Myorelaxants.

Special procedures
Regional anesthesia Nerve block (using alcohol or phenol) Acupuncture. Neuro-ablation:
anterolateral chordotomy precentral lobotomy.

Other pain relieving modalities

Radiation. Chemotherapy. Surgery.

Mechanism of Action analgesics

NSAID , eg ibuprofen, minimize the effects of pain mediators released, especially PGs. Narcotics block the release of neurotransmitters

Mechanism of Action adjuvants

Corticosteroids, interferes with the production of PGs. Antidepressants interfere with the reuptake of serotonin and norepinephrine which is important in Cancer pain. local anesthetics, anticonvulsants decrease the sodium and potassium transfers at the neuron level, used for neuropathic pain, migraines.

PAIN RELIEF
START WITH NON OPOID DRUG WITH OR WITHOUT AN ADJUVANT. PAIN :Opoid drug for mild to moderate pain with or without adjuvant. PAIN :Opoid drug for moderate to severe pain with or without adjuvant. FREEDOM FROM CANCER PAIN

FREEDOM FROM PAIN

Opoid for moderate to severe pain +/- non opoid W/without adjuvant.

Pain persisting or increasing

Opoid for mild to moderate pain+ non opoid W/without adjuvant.

Pain persisting or increasing

Non opoid +adjuvant

Aims
Increase the hours of painless sleep. Relieve the rest pain. Relieve active time pain.

Faculty of Pain Medicine

The establishment of the Faculty of Pain Medicine within the College of Anaesthetists, incorporating true multidisciplinary representation from other medical specialties, is an important and innovative advance in dealing with the management of acute, chronic nonmalignant and cancer pain which collectively remain one of society's major problems www.fpm.anzca.edu.au/

"Patients in pain require a specialty that is unencumbered by the boundaries of traditional disciplines, one that is able to assimilate diverse knowledge and treatments in order to provide sound care. and to produce role models, teachers, and researchers as the science and practice of pain medicine continues to expand". The Case for Pain Medicine Fishman S et al Pain Medicine 2004, 5:281-286

Pain is a more terrible lord of mankind than death itself.

Albert Schweitzer