Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Chapter Ten: The Management of Pain and Discomfort

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The elusive nature of pain Clinical issues in pain management Pain control techniques Pain management programs 2

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Provides low-level feedback about the functioning of our bodily systems Can lead a person to seek treatment Inadequate relief from pain is the most common reason for requests for euthanasia or assisted suicide 3

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Degree to which pain is felt depends on: How it is interpreted Context in which it is experienced Cultural component - Members from some cultures react more intensely to it than those from other cultures Gender differences - Women show greater sensitivity to pain 4

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Verbal reports - Large, informal vocabulary that people use for describing pain Pain questionnaires - Ask about the nature of pain and its intensity 5

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Addressing the psychosocial components of pain - How much: Fear it causes It has taken over a person’s life 6

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Methodological tools can be used to gain insights about pain Pain behaviors: Arise from chronic pain Assess how pain has disrupted a patient’s life Help define the characteristics of different pain syndromes 7

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Protective mechanism to bring tissue damage into conscious awareness Accompanied by motivational and behavioral responses Negative emotions exacerbate pain and vice versa 8

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Results from mechanical damage to the tissues of the body Nociception: Pain perception Mechanical nociception Experience of pain due to temperature exposure Thermal damage Pain that triggers chemical reactions from tissue damage Polymodal nociception 9

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Developed scientific understanding of pain Nociceptors sense injury and release chemical messengers to the spinal cord A-delta fibers - Small, myelinated fibers Respond to mechanical or thermal pain Transmit sharp, brief pains rapidly 10

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. C-fibers - Unmyelinated nerve fibers Involved in polymodal pain Transmit dull, aching pain Periductal gray - Located in the midbrain Results in pain relief when stimulated Processes in the cerebral cortex are involved in cognitive judgments about pain 11

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. 12

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Endogenous opioid peptides: Natural pain suppression system of the body Stress-induced analgesia (SIA) - Phenomenon where acute stress reduces sensitivity to pain 13

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Acute pain: Results from a specific injury that produces tissue damage Disappears when the tissue is repaired Short in duration, lasting for 6 months or less Chronic pain: Begins with an acute episode but does not decrease with treatment and the passage of time 14

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Persists for 6 months or longer Relatively unresponsive to treatment Severity of pain varies Chronic benign pain Intermittent episodes of pain that are acute in character but chronic in condition Recurs for more than 6 months Recurrent acute pain Persists longer than 6 months and severity increases over time Associated with malignancies or degenerative disorders Chronic progressive pain 15

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Source: National Institute of Neurological Disorders and Stroke,

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Both have different psychological profiles Chronic pain Has an overlay of psychological distress that complicates diagnosis and treatment Patients develop maladaptive coping strategies Interaction of physiological, psychological, social, and behavioral components Pain control techniques are not effective 17

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Reacting to a bodily insult with a specific bodily response Exacerbated by stress or by efforts to suppress pain High sensitivity to noxious stimulation Impairment in pain regulatory systems Psychological distress 18

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Pain is exacerbated by: Inappropriate prior treatments Misdiagnosis or inappropriate prescriptions of medications Lifestyle Quit jobs and abandon leisure activities Withdraw from families and friends Require public assistance 19

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Experience loss of self-esteem Receive compensation Increases pain as it provides an incentive for being in pain Relationships Family relationships get affected Positive attention from spouse may maintain the pain 20

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Behaviors - Alterations in lifestyle interfere with successful treatment Factors in treating the total pain experience Understanding the pain behaviors Knowing whether they persist after treatment 21

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Pain-prone personality: Predispose a person to experience chronic pain Personality attributes associated with chronic pain Neuroticism Introversion Use of passive coping strategies 22

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Minnesota Multiphasic Personality Inventory (MMPI) - Instrument used to develop pain profiles Conditions that increase the perception of pain Depression and anger suppression Anxiety disorders, substance use disorders, and other psychiatric problems 23

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Area that once hurt does not hurt anymore Person feels sensation but not pain Person feels pain but is not concerned about it Person is still hurting but is able to tolerate it 24

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Most common method of controlling pain Administration of drugs Local anesthetics - Affect the transmission of pain impulses from peripheral receptors to the spinal cord Spinal blocking agents Antidepressants - Affect the downward pathways from the brain that modulate pain Types of drugs Undesirable side effects Addiction Drawbacks 25

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Disrupt the conduct of pain from the periphery to the spinal cord Interrupt the flow of pain sensations from the spinal cord upward to the brain Drawbacks Effects are short-lived and it is very expensive Surgery damages the nervous system 26

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Counterirritation: Inhibiting pain in one part of the body by stimulating or mildly irritating another area Exercise and other ways of increasing mobility help the chronic pain patient 27

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Requires patients to actively participate and learn More effective for managing slow-rising pains 28

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Providing biophysiological feedback to a patient about some bodily process of which the patient is unaware Target function to be controlled is identified and tracked by a machine Patient attempts to change the bodily process with the help of continuous feedback 29

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Shifting the body into a state of low arousal by progressively relaxing different parts of the body using controlled breathing Beneficial physiological effects are due to the release of endogenous opioid mechanisms 30

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Turning attention away from pain by: Focusing on an irrelevant and attention- getting stimulus Distracting oneself with a high level of activity Most effective for coping with low-level pain 31

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Helps chronic pain patients manage pain Expected duration of pain determines which coping strategy a patient should be trained in 32

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Reconceptualizes a problem from overwhelming to manageable Patients: Believe that the required skills will be taught to them Become competent individuals aiding in the control of pain 33

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learn to break up maladaptive behavioral syndromes Learn to make adaptive responses to pain Are encouraged to attribute their success to their own efforts Are taught relapse prevention Are trained to control their emotional responses to pain 34

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Interdisciplinary efforts, bringing together neurological, cognitive, behavioral, and psychological expertise concerning pain Steps Initial evaluation Individualized treatment 35

Copyright © 2015 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Components Patient education Involvement of family Relapse prevention 36