Introduction to pain Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

Objectives By the end of the session, learners should be able to: 1.Define the term pain 2.Name the common opioid analgesics 3.Understand that the World Health Organization considers morphine to be an essential medicine 4.Describe the disparity in access to morphine by country income level 5.Give key advantages of morphine relative to other pain medicines 6.Describe challenges that limit access to morphine 7.Understand why pain treatment is important 8.Name the simple treatment algorithm that relieves pain in 80-90% of people 9.Challenge some common myths about pain treatment 2

Pain Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage Pain is a subjective experience. The experience varies from person to person and from time to time – Pain is whatever the experiencing person says it is, existing wherever he says it does 3 Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. (1979). Pain, 6(3), 249.; McCaffery, (1968)

Total pain: how patients experience pain 4 TOTAL PAIN PHYSICAL PSYCHOLOGICALEMOTIONAL SPIRITUAL Patients experience pain on several levels and effective treatment requires a holistic assessment This training program focuses on physical pain

Who suffers from pain? Pain is prevalent in almost all medical specialties including general practice, palliative care, oncology, internal medicine, haematology, and surgery Patients who are affected include people who have cancer, HIV, sickle-cell disease, those who have surgery or accidents, and potentially other patients Approximately 80% of people with advanced cancer and 50% of people with advanced HIV experience moderate or severe pain 5 Ensuring balance in national policies on controlled substances: guidance for availability and accessibility of controlled medicines. World Health Organization (2011); Foley et al. Pain Control for People with Cancer and AIDS (2006)

Opioid analgesics for pain relief Analgesics are medicines that relieve pain Opioids are medicines that are derived from opium poppy plants or synthetic formulations that act in the same way – Weak opioids Codeine Tramadol Dihydrocodeine – Strong opioids Morphine Fentanyl Oxycodone Hydrocodone Buprenorphine Methadone 6Beating Pain, 2 nd Ed. APCA (2012)

World Health Organization Opioid analgesics, including morphine, are considered essential medicines by the World Health Organization Strong opioid analgesics are the only treatment for moderate or severe pain recommended in World Health Organization guidelines No suitable alternatives have been found 7 Ensuring balance in national policies on controlled substances: guidance for availability and accessibility of controlled medicines. World Health Organization (2011)

Disparity in access to opioids Opioids are on almost all national essential medicines lists, but access to them is severely limited in most low and middle- income countries, where 85% of the world’s population consumes just 7% of the medicinal opioids 8Treat the Pain: based on data from the International Narcotics Control Board and WHO Cause of Death data (2012)

Number of deaths with untreated pain (2012) 9 Deaths with untreated pain The lowest treatment coverage rates are: South Asia: 9% Sub-Saharan Africa: 20% Treat the Pain: based on data from the International Narcotics Control Board and WHO Cause of Death data (2012)

Access to morphine differs according to country income level Maximum coverage rate for deaths in pain from HIV or cancer based on national consumption of opioid analgesics: High-income countries: 100% Middle-income countries: 62% Low-income countries: 19% People in lower income countries are significantly less likely to get pain treatment than people in higher-income countries 10Treat the Pain: based on data from the International Narcotics Control Board and WHO Cause of Death data (2012)

Opioid analgesics for pain relief Opioids are the foundation of pain management for moderate or severe pain No organ toxicity, even at high doses and after prolonged use Side effects diminish over time Potential harmful side effects are avoidable when opioids are used correctly 11IASP: Treatment of pain in low-resource settings (2010)

Morphine advantages Most effective treatment for severe pain Safe (if used according to guidelines) Effective Plentiful Inexpensive Easy-to-use 12Beating Pain, 2 nd Ed. APCA (2012)

Challenges that limit access to morphine Although morphine is inexpensive people lack access due to: Inadequate training or lack of knowledge of healthcare providers Cultural misperceptions about pain Lack of appropriate government policies or guidelines Legal and regulatory restrictions Weak procurement systems Disproportionate concern about diversion, addiction, and abuse Practices meant to prevent abuse of morphine that result in limited access for those in need of pain relief 13IASP: Treatment of pain in low-resource settings (2010)

Advantages of pain treatment In low-resource countries, pain is the most common indication for visiting a health care practitioner Pain treatment: Improves compliance to curative treatment Extends survival for some patients Improves quality of life Improves patient – physician relationship Reduces unnecessary prolonged admission IASP: Treatment of pain in low-resource settings (2010); Temel et al- NEJM (2010)14

How to treat pain? The World Health Organization has developed a simple algorithm, or model for pain treatment: the WHO Analgesic Ladder – Incorporates non-opioid and opioid pain relievers – Extremely effective for patients with acute pain, cancer pain, and neuropathic pain (nerve pain) 80-90% of people are effectively treated IASP: Treatment of pain in low-resource settings (2010); 15

Dispelling some myths Myth: Children don’t feel pain – There is no evidence that neonates or young children feel less pain than adults Myth: Moderate or severe pain is uncommon – Approximately 50% of people with advanced HIV and 80% of people with advanced cancer will experience moderate or severe pain – Other causes of pain include surgery, trauma, burns, myocardial infarction, sickle cell disease, and childbirth 16 IASP: Treatment of pain in low-resource settings (2010); Children’s Palliative Care in Africa; Ensuring balance in national policies on controlled substances: guidance for availability and accessibility of controlled medicines. World Health Organization (2011); Foley et al. Pain Control for People with Cancer and AIDS (2006)

Dispelling some myths Myth: Opioids are dangerous According to the World Health Organization: – “Opioid analgesics, if prescribed in accordance with established dosage regimens, are known to be safe and there is no need to fear accidental death or dependence.” – “A systematic review of research papers concludes that only 0.43% of patients with no previous history of substance abuse treated with opioid analgesics to relieve pain abused their medication and only 0.05% developed dependence syndrome.” 17 World Health Organization: Ensuring Balance in National Policies on Controlled Substances: 2011

Dispelling some myths Myth: Pain relief is not affordable – Locally produced oral morphine solution costs just 3.30 USD per week in Uganda and 5.00 USD per week in Nigeria – Tablets or injectable opioids may be more expensive Myth: Morphine is only appropriate for patients at the end of life – Morphine allows many patients who are not dying, but are limited by pain, to live a more active life – Pain treatment should be determined by the level and type of pain, not the stage of disease 18Treat the Pain Costing Data, 2014.

Take home messages The advent of the WHO analgesic ladder means that all health care providers can provide effective, high-quality pain treatment Pain assessment and treatment should be integrated into service delivery in all departments Specialists in palliative care or anesthesiology can be called on for complex cases Patients should be informed about pain and pain relief measures 19

Upcoming pain sessions in the series Mechanism of pain Pain assessment Treatment with the WHO Analgesic Ladder Use of adjuvants or co-analgesia Pain emergencies and incident and breakthrough pain 20

References African Palliative Care Association. Beating Pain: a pocketguide for pain management in Africa, 2nd Ed. [Internet] Available from: African Palliative Care Association. Using opioids to manage pain: a pocket guide for health professionals in Africa [Internet] Available from: Amery J, editor. Children’s Palliative Care in Africa [Internet] Available from: Full-Text.pdf Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings [Internet] Available from: pain.org/files/Content/ContentFolders/Publications2/FreeBooks/Guide_to_Pain_Mana gement_in_Low-Resource_Settings.pdf The Palliative Care Association of Uganda and the Uganda Ministry of Health. Introductory Palliative Care Course for Healthcare Professionals