Pain Management Patrice Levy, RN Therapeutics NURS 7724 November 25, 2002

Objectives Define pain Define addiction, physical dependence, tolerance, and adjuvant analgesic Identify the types/classification of pain Explain the pain mechanisms Identify the barriers to pain management and harmful effects of unrelieved pain

Definition of Pain Pain is an unpleasant sensory and emotional experience associated with acute or potential tissue damage, or described in terms of such damage. IASP, APS - 1992, Mersky, Bogduk - 1994 Most widely accepted definition of pain. Adopted by the International Association for the study of pain and the American Pain Society. Pain has multiple components which impact on the psychological and physical function of the individual. Chronic pain- pain may be described as much more severe than the actual tissue damage that is seen.

Definition of Pain Pain is whatever the experiencing person says it is, existing whenever he says it does McCaffery - 1968 Identifies pain as a personal/subjective experience

Definitions Addiction: Psychologic dependence. A pattern of compulsive drug use characterized by continued craving for an opioid for effects other than pain relief. Tolerance: A decrease in one or more effects of the opioid Physical Dependence: is the occurrence of withdrawal symptoms when the drug is stopped. Tolerance to analgesia may be treated with increasing the dose. Withdrawal symptoms usually are suppressed by gradual withdrawal of the opioid.

Definitions Adjuvant analgesic: A drug that has a primary indication other than pain. Adjuvant analgesics may be used both as “add-on” therapy to an opioid regimen or as distinct primary therapy in certain painful disorders. Antidepressant medications are used for chronic pain. Anticonvulsants are used for neuropathic pain. Anticonvulsant drugs are used for neuropathic pain.

Types of Pain Acute Pain- brief pain that subsides as healing takes place Cancer Pain Chronic Nonmalignant Pain A clear distinction between the types of pain is not always possible. There is some overlap and some omissions but treatment of pain is affected by the classification. Acute pain- brief pain that subsides as healing takes place. Usually treated with IV meds. Cancer pain has an ending (limited by cure, control, or death) Cancer pain is usually both nociceptive and neuropathic. Treatment is opioids by mouth.i

Classification of Pain Nociceptive- term used to describe how pain becomes conscious Neuropathic- abnormal processing of sensory input by the peripheral or CNS

Nociception Pain Pathway Transduction- Conversion of one energy from another, begins in the periphery when a noxious stimulus causes tissue damage. Transmission- movement of impulses from the site of transduction to the brain. Perception- conscious experience of pain. Modulation- inhibition of nociceptive impulses. Transduction: Sensitizing substances released by damaged cell: prsotaglandins bradykinin serotonin substance P histimine An action potential results from the release of the above sensitizing substances.

Nociception - The Process

Nociceptive Pain Somatic Pain- arises from bones, joints, muscle, or connective tissue. Usually described as aching or throbbing in quality. Pain is well localized. Visceral Pain- arises from the visceral organs, GI tract/pancreas. Visceral Pain: tumor involvement of the organ capsule may cause an aching and fairly well localized pain. Obstruction of the hollow viscus causes interm ttent cramping and poorly localized pain.

Neuropathic Pain Centrally Generated- results from injury to the CNS or peripheral nervous system Peripherally Generated- generalized or specific pain along a damaged nerve. Centrally generated deafferentation pain results from injury to central or peripheral nervous system- phantom pain- injury to peripheral nervous system or burning pain below a spinal cord lesion- injury to the CNS. Peripheral pain- diabetic neuropathy- generalized or specific pain along a damaged nerve- trigeminal neuralgia. In some cases- phantom limb pain the injury is peripheral, but the pain is generated in the CNS.

Barriers to Pain Management Health Care Professionals Inadequate knowledge Lack of education Poor assessment Regulatory Constraints Education is being provided through City of Hope, (Robert Wood Johnson Grants), Curriculum Guidelines IASP (International Association for the study of Pain). Clinical Practice Guidelines- APS (American Pain Society), AHCPR (Agency for Health Care Policy and Research). Assessment- pain is subjective and in the medical model pain management was dictated by personal opinion. Pain can not be proved or disproved. Addiction is very rare- less than 1%. Regulatory issues: Non issue if documentation is appropriate!

Barriers of Pain Management Patients and the Public Reluctance to report pain Reluctance to take analgesics Concerns about addiction Concerns about tolerance Desire to be a “good patient” People are afraid of becoming overly reliant on medication and ultimately addicted. People also fear that medication will become ineffective with continued use. In a 1995 survey, published in the Journal of the American Medical Association, approximately 50% of one group of more than 4,000 conscious patients who died in hospitals were reportedly in moderate to severe pain during the last eight days of their lives (Rubinger and Gardner, 2002). Patient’s Bill of Right’s- Right to have reports of pain accepted and acted upon.. Right to have pain controlled. The right to be treated with respect at all times.

Barriers to Pain Management Health Care System Pain assessment and treatment a low priority in daily practice Restrictive regulation of controlled substances Lack of accountability- pain not treated as a priority issue. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently adopted standards for pain management. The standards, which address how a person’s pain is to be assessed and managed went into effect on Jan. 1, 2001(Rubinger and Gardner, 2002).

Harmful Effects of Unrelieved Pain Endocrine System overactivity Cardiovascular Hypercoagulation Increase Heart Rate Increase Blood Pressure Increase Cardiac Workload Increase Oxygen Demand Respiratory Muscle Spasm Decrease Tidal Volume Decrease Vital Capacity Decrease Alveolar Ventilation Genitourinary Urinary Retention Hypokalemia The pain involved in surgical procedures, trauma and tumor growth trigger stress responses which activate the SNS which alerts the body to impending or existing harm. Over activity of the endocrine system can cause protein catabolism, hyperglycemia, weight loss, tachycardia, increased respiratory rate, fever, shock and death. NSAID’s and opioids have been shown to slow the metabolic response to stress. Cardiovascular systems responds by activating the SNS. Respiratory- muscle spasms at the site of tissue damage leads to splinting and immobility. The decrease in lung function can lead to pneumonia. Hypoxia can result in cardiac complications poor wound healing and mental dysfunction.. GU- hormones that regulate the uo can be excessively released during periods of uncontrolled pain. This can result in urinary retention, hypokalemia, fluid overload, increased cardiac workload, and hypertension.

Harmful Effects of Unrelieved Pain Gastrointestinal Increase intestinal Secretion Increase smooth muscle tone Decrease Gastric Emptying Decrease Intestinal Motility Musculoskelatal Muscle Spasm Impaired Function Fatigue Imobility Cognitive Function Mental Decline Immune Function Decrease Immune Function Decrease NK Cell Activity Developmental Effect Experience associated with pain remembered and this can have an effect on future behavior Stress response causes an increase in SNS activity which causes an increase in intestinal secretions and smooth muscle sphincter tone increase. It also causes a decrease in gastric emptying and intestinal motility. Musculoskeletal system- pain causes muscle spasm, impaired muscle function, fatigue, and immobility. Cognitive function- post op transient decrease in cognitive function normal about 2 days post op with recovery in 1 week. Immune system- Immunosuppression can predispose people to post op infections.

Harmful Effects of Unrelieved Pain Future Pain Poorly controlled acute pain can predispose patients to debilitating pain syndromes. Phantom Pain Herpetic Pain Quality of Life Impact of unrelieved pain on quality of life is significant , ranging from decreased physical activity to hopelessness and suicidal ideations Post mastectomy, post thoracotomy, post amputation- the pain mechanism is neuropathic and results from musculoskeltal changes and injury to the peripheral nerves. Phantom pain can be severe and descriptors include continuous burning, cramping, throbbing, crushing, sharp, or shooting. Incidence of phantom limb pain is greater in those individuals who have pain before the surgery. Pain related to Herpes Zoster- most common symptom of herpes- pain described as burning, sensitive to touch, deep aching, itching, stabbing, and paroxysmal. Pain is along the nerve distribution. Quality of Life- the loss of control, autonomy, sexual activity, sleep, and the ability to work.

Conclusion The power point presentation on pain management discussed the basic mechanisms underlying the causes and effects of pain.

References Fanciullo, G, (2000). Acute Pain Management , Symposium Spotlight: The 16th Annual Meeting of the American Academy of Pain Medicine, New Orleans, La., Feb. 24-27. Joint Commission on Accreditation of Healthcare Organization, (2000). Pain assessment and management an organizational approach. Oakbrook, Il.: Joint Commission on Accreditation of Healthcare Organization. McCaffery, M. & Ferrell, B. (1999). Pain Clinical Manual (2nd ed.). St. Louis: Mosby. Phillips, D. (2000). JCAHO pain management standards are unveiled, JAMA, 284 (4). Rubinger, H, & Gardner, Richard, (2002). Pain and Suffering, Continuing Care, 21, (4), 22. Smith,Rita, Curi, M., Silverman, A, (2002). Pain Management: The global connection, Nursing Management, 33 (6), 27. Stratton, L. (1999). Evaluating the effectiveness of a hospital pain management program, Journal of Nursing Care Quality, 13 (4), 8-18. U.S. Department of Health and Human Services, Agency for Health Care Policy and Research: Acute Pain Management in Adults: Operative Procedures. Pub 92-0019.