1. ESSENTIAL PAIN MANAGEMENT EPM Lite CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License. 1.1

2. EPM Lite Aims 1.To improve understanding of pain 2.To teach the RAT approach to pain management 1.2

3. Workshop Plan Pain basics – What is pain? – Why should we treat pain? – Classification of pain – Physiology and pathology – Pain treatment RAT approach Case discussions 1.3

4. Untreated Pain 1.4

5. Untreated Pain Often hidden (not recognized) Causes a lot of suffering But … can often be treated simply and cheaply 1.5

6. Approach to Pain Recognize Assess Treat 1.6

7. Approach to Pain R Recognize – Does the patient have pain? – Do other people know the patient has pain? 1.7

8. Approach to Pain A Assess – How severe is the pain? – What type of pain is it? – Are there other factors? 1.8

9. Approach to Pain T Treat – What non-drug treatments can I use? – What drug treatments can I use? 1.9

10. ? 1.10

11. Introduction Summary At the end of this workshop, you will be will: 1.Understand the importance of treating pain. 2.Be able to use RAT to manage different types of pain. 1.11

12. What is Pain and Why Treat It? CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License. 2.1

13. What is Pain & Why Treat It? Aims To define pain To understand the reasons for treating pain To understand the benefits for the patient, family and society 2.2

14. What is Pain & Why Treat It? Group discussion (Think of a patient / friend / relative who had pain or use your pre-prepared case.) – How did the person describe the pain? – What were the benefits of treating his/her pain? 2.3

15. What is Pain? International Association for the Study of Pain – Pain is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. Are there any other definitions? 2.4

16. What is Pain? Unpleasant Emotions are important The cause is not always visible “Pain is what the patient says hurts.” 2.5

17. Is this man feeling pain? 2.6

18. Benefits of Treating Pain For the patient – Physical Improved sleep, better appetite Fewer medical complications (e.g. heart attack, pneumonia) – Psychological Reduced suffering Less depression, anxiety 2.7

19. Benefits of Treating Pain For the family – Improved functioning as a family member (e.g. as a father or mother) – Able to keep working For society – Lower health costs (e.g. shorter hospital stay) – Able to contribute to the community 2.8

20. ? 2.9

21. What is Pain & Why Treat It? Summary Pain is an unpleasant sensory and emotional experience Pain is what the patient says hurts Treating pain is the “humane” thing to do Treating pain has many other benefits 2.10

22. Classification of Pain CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License. 3.1

23. Classification of Pain Aims To classify types of pain To understand that treatment depends on the pain type 3.2

24. Classification of Pain Not all pain is the same Three main questions: 1.How long has the patient had pain? 2.What is the cause? 3.What is the mechanism? 3.3

25. Classification of Pain DurationAcute Chronic Acute on chronic CauseCancer Non-cancer MechanismNociceptive Neuropathic 3.4

26. Acute versus Chronic Acute – Pain of recent onset and probable limited duration Chronic – Pain lasting for more than 3 months – Pain lasting after normal healing – Often no identifiable cause 3.5

27. Cancer versus Non-Cancer Cancer pain – Progressive – May be mixture of acute and chronic Non-cancer pain – Many different causes – Acute or chronic Can you give examples of non-cancer pain? 3.6

28. Nociceptive Pain Obvious tissue injury or illness Also called physiological or inflammatory pain Protective function Description – Sharp ± dull – Well localised Can you give examples? 3.7

29. Neuropathic Pain Nervous system damage or abnormality Tissue injury may not be obvious Does not have a protective function Description – Burning, shooting ± numbness, pins and needles – Not well localised Can you give examples? 3.8

30. Examples of Pain Types 3.9

31. Acute Non-Cancer Pain Examples – Fracture, appendicitis Symptom of tissue injury or illness Usually nociceptive Occasionally neuropathic (e.g. sciatica) 3.10

32. Chronic Non-Cancer Pain Examples – Chronic back pain, arthritis Injury may not be obvious Complex, may be mixed nociceptive and neuropathic Does not respond to usual drug treatment 3.11

33. Cancer Pain Examples – Uterine cervical cancer, breast cancer Features of acute and chronic pain – May be acute on chronic Often mixed nociceptive and neuropathic pain Usually gets worse over time if untreated 3.12

34. ? 3.13

35. Classification of Pain Summary Deciding on the type of pain is important – Acute / chronic – Cancer / non-cancer – Nociceptive / neuropathic Treatment depends on the pain type 3.14

36. Pain Physiology and Pathology CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License. 4.1

37. Pain Physiology and Pathology Aims To understand normal pain physiology – Nociceptive pathway – Factors affecting the pain signal To understand the basis of neuopathic pain (pathology) 4.2

38. Nociception and Pain Nociception – How signals get from the site of injury to the brain Pain perception – How we “feel” pain Nociception is not the same as pain! 4.3

39. Is this man feeling pain? 4.4

40. Pain What the patient says hurts. What must be treated. Injury Beliefs/concerns about pain Psychol. factors anxiety/anger/depression Cultural issues Language, expectations Other illnesses Coping strategies Social factors e.g. family, work Nociception is not the same as pain! Modified from Analgesic Expert Group. Therapeutic Guidelines 2007 4.5

41. Physiology 4 steps: – Periphery – Spinal cord – Brain – Modulation We will look at each step 4.6

42. Periphery Tissue injury Release of chemicals Stimulation of pain receptors (nociceptors) Signal travels in Aδ or C nerve to spinal cord 4.7

43. Spinal Cord Dorsal horn is the first relay station Aδ or C nerve synapses (connects) with second nerve Second nerve travels up opposite side of spinal cord 4.8

44. Brain Thalamus is the second relay station Connections to many parts of the brain – Cortex – Limbic system – Brainstem Pain perception occurs in the cortex 4.9

45. Modulation Descending pathway from brain to dorsal horn Usually decreases pain signal 4.10

46. Placebo Treatment Psychological factors are important. If a placebo treatment works, this does not mean the patient did not have pain or was telling lies! 4.11

47. Why is pain physiology important? Many factors affect how we “feel” pain. – Psychological factors are very important. Different treatments work on different parts of the pathway. – More than one treatment may be needed. 4.12

48. Pain Pathology Abnormal processing of pain signal Nervous system damage or dysfunction Needs to be treated differently Examples – Nerve trauma, diabetic pain (damage) – Fibromyalgia, chronic tension headache (dysfunction) 4.13

49. Pathological Mechanisms Increased receptor numbers Abnormal sensitisation of nerves – Peripheral – Central Chemical changes in the dorsal horn Loss of normal inhibitory modulation How do patients describe their pain? 4.14

50. ? 4.15

51. Pain Physiology and Pathology Summary Many factors affect how we “feel” pain. Different treatments work on different parts of the nociceptive pathway. Neuropathic pain needs to be treated differently. 4.16

52. Pain Treatment Overview CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License. 5.1

53. Pain Treatment Overview Aims To classify non-drug and drug treatments To summarise the major advantages and disadvantages of important drugs 5.2

54. Pain Treatment 5.3 Group brainstorming – What non-drug treatments are available? – What drug treatments are available?

55. Non-Drug Treatments Physical – Rest, ice, compression, elevation – Surgery – Acupuncture, massage, physiotherapy Psychological – Explanation – Reassurance – Counselling 5.4

56. Drug Classification Simple analgesics – Paracetamol (acetaminophen) – Anti-inflammatory medicines – Diclofenac, ibuprofen Opioids – Mild – Codeine – Strong – Morphine, pethidine, oxycodone 5.5

57. Drug Classification Other analgesics – Tramadol – Tricyclic antidepressants (e.g. amitriptyline) – Anticonvulsants (e.g. gabapentin) – Ketamine – Local anaesthetics – Clonidine 5.6

58. Treatments - Periphery Non-drug treatments – Rest, ice, compression, elevation Anti-inflammatory medicines Local anaesthetics 5.7

59. Treatments - Spinal Cord Non-drug treatments – Acupuncture, massage Local anaesthetics Opioids Ketamine 5.8

60. Treatments - Brain Non-drug treatments – Psychological Drug treatments – Paracetamol – Opioids – Amitriptyline – Clonidine 5.9

61. Paracetamol (Acetaminophen) Advantages – Cheap, safe – Can be given orally, rectally or intravenously – Good for: Mild pain (by itself) Mod-severe pain (with other drugs) Disadvantages – Liver damage in overdose 5.10

62. Anti-Inflammatory Medicines Aspirin, ibuprofen, diclofenac Advantages – Cheap, generally safe – Good for nociceptive pain Best given regularly with paracetamol Disadvantages – Gastrointestinal and renal side effects 5.11

63. Codeine Advantages – Cheap, safe – Good for mild-moderate acute nociceptive pain Best given regularly with paracetamol Disadvantages – Constipation – Not good for chronic pain – Misunderstandings about addiction 5.12

64. Opioids and Addiction Pain is sometimes poorly treated because of concerns about addiction. Addiction is very rare in: – Acute pain – Cancer pain Addiction is more likely in chronic non-cancer pain. 5.13

65. Morphine 1 Advantages – Cheap, generally safe – Can be given orally, IV, IM, SC – Effective if given regularly – Good for: Mod-severe acute nociceptive pain (e.g. post-op pain) Chronic cancer pain 5.14

66. Morphine 2 Disadvantages – Constipation – Respiratory depression in high dose – Misunderstandings about addiction – Controlled drug Oral dose is 2-3 times IV / IM / SC dose Why is this? 5.15

67. Pethidine (Meperidine) Can be good for severe acute nociceptive pain but has more disadvantages than morphine Disadvantages – Also a controlled drug – Must be given more frequently than morphine – Breakdown product (norpethidine) can cause convulsions – Not good for chronic pain 5.16

68. Tramadol Weak opioid effect plus inhibitor of serotonin and noradrenaline reuptake (modulation) Advantages – Less respiratory depression – Can be used with opioids and simple analgesics – Not a controlled drug Disadvantages – Nausea and vomiting 5.17

69. Amitriptyline Tricyclic antidepressant (TCA) Increases descending inhibitory signals Advantages – Cheap, safe in low dose – Good for neuropathic pain – Also treats depression, poor sleep Disadvantages – Anti-cholinergic side effects (e.g. glaucoma, urinary retention) 5.18

70. Anticonvulsant Drugs Examples – Carbamazepine (Tegretol) – Sodium valproate (Epilim) – Gabapentin (Neurontin) Also called membrane stabilisers – Reduce abnormal firing of nerves Good for neuropathic pain 5.19

71. Drug Effectiveness Acute noci mild Acute noci severe Acute neuro Chronic non- cancer Chronic cancer Paracetamol ++++++++ NSAIMs ++ +±± Codeine +++± Morphine +++++-+++ TCAs --++ Anticonvulsants --++ + 5.20

72. ? 5.21

73. Pain Treatment Overview Summary Both non-drug and drug treatments are important. Different treatments work on different parts of the pain pathway – combinations are good. Analgesics can be classified into simple analgesics, opioids and other drugs. 5.22

74. The RAT Approach to Pain Management CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License. 6.1

75. RAT Approach Aims To give a simple framework for managing patients with pain To illustrate the use of this framework for different types of pain 6.2

76. RAT Approach 6.3

77. RAT Approach 6.4 Recognize Assess – Severity? – Type? – Other factors? Treat – Non-drug treatments – Drug treatments

78. Recognize Does this person have pain? 6.5 Credit: “Neutral face” - Oosterhof & Todorov

79. Recognize Does the patient have pain? – Ask – Look (frowning, moving easily, sweating?) Do other people know the patient has pain? – Other health workers – Patient’s family 6.6

80. Assess 1 What is the severity? What is the pain score? – At rest – With movement How is the pain affecting the patient? – Can the patient move, cough? – Can the patient work? 6.7

81. Measuring Severity Helps guide treatment Methods – Verbal (e.g. mild, moderate, severe) – Numerical 0 (no pain) to 10 (worst pain imaginable) – Visual Visual Analogue Scale (VAS) “Faces” pain scale 6.8

82. Numerical Scale 6.9

83. Faces Pain Scale 6.10

84. Assess 2 What is the pain type? Acute or chronic? Cancer or non-cancer? Nociceptive or neuropathic? – Look for neuropathic features: Burning or shooting pain Phantom limb pain Other features (pins and needles, numbness) 6.11

85. Assess 3 Are there other factors? Physical factors (other illnesses) Psychological and social factors – Anger, anxiety, depression – Lack of social supports 6.12

86. Treat 1 Non-Drug Treatments RICE – Rest, ice, compression, elevation of injuries Nursing care Surgery, acupuncture, massage etc Psychological – Explanation and reassurance – Input from social worker / pastor 6.13

87. Treat 2 Drug Treatments Nociceptive Pain – Mild Paracetamol (± NSAIM) – Moderate Paracetamol (± NSAIM) + codeine – Severe Paracetamol (± NSAIM) + morphine 6.14

88. Treat 2 Drug Treatments Neuropathic Pain – Traditional drugs may not be as useful – Use other drugs early Amitriptyline Gabapentin / carbamazepine – Don’t forget non-drug treatments 6.15

89. After RAT Reassess the patient – Is your treatment working? – Are other treatments needed? 9.16

90. Example 1 A 32-year-old man caught his right hand in machinery at work. He presents with a compound fracture of his hand. How would you manage his pain using the RAT approach? 6.17

91. Example 2 A 55-year-old woman presents with a large breast tumour with spread to her spine. She has severe pain. How would you manage her pain using the RAT approach? 6.18

92. Example 3 A 51-year-old man has a 2 year history of lower back pain which sometimes radiates down his right leg. He fell recently and is now having problems walking. How would you manage his pain using the RAT approach? 6.19

93. ? 6.20

94. RAT Approach Summary Recognize Assess – Severity? – Type? – Other factors? Treat – Non-drug treatments – Drug treatments 6.21