1. ESSENTIAL PAIN MANAGEMENT
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2. EPM Aims To improve understanding of pain
To teach a simple framework for managing pain
To reduce pain management barriers

3. Workshop Plan 1 Pain basics What is pain? Why should we treat pain?
Classification of pain
Physiology and pathology
Pain treatment
Barriers to treatment

4. Workshop Plan 2 Practical pain management Case discussions
Overcoming barriers

5. Untreated Pain

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

7. Approach to Pain
Recognize
Assess
Treat

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

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

10. Approach to Pain T Treat What non-drug treatments can I use?
What drug treatments can I use?

11. ?

12. Introduction Summary At the end of this course, you will be able to:
Understand the importance of treating pain
Recognize, assess and treat different types of pain
Identify and address barriers where you work

13. What is Pain?
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14. What is Pain? Aims
To define pain
To give examples of pain

15. What is Pain? Group discussion
Think of a patient / friend / relative who had pain.
How did the person describe the pain?
How was it treated?

16. 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”.
What does this mean?
Are there any other definitions?

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

18. Is this man feeling pain?

19. ?

20. What is Pain? Summary
Pain is an unpleasant sensory and emotional experience
Pain is what the patient says hurts!

21. Why Should We Treat Pain?
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22. Why Should We Treat Pain? Aims
To understand the reasons for treating pain
To understand the benefits for the patient, family and society

23. Case 1
Mr T is a 29-year-old man with a fast growing mouth cancer that has spread to his bones. He has severe face pain. He is expected to die within 6 months and the surgeons do not want to operate. He is married with two children, aged 11 and 8
Why should we treat his pain?

24. Case 2
Mrs G is a 54-year-old woman who has just had a laparotomy for bowel obstruction. You see her on the surgical ward soon after the operation. She appears to be in pain.
Why should we treat her pain?

25. Why Pain Matters For the patient Physical Psychological
Suffering, poor sleep, decreased appetite
Medical complications
(e.g. heart attack, pneumonia)
Psychological
Depression, anxiety

26. Why Pain Matters For the family For society
Unable to function as part of the family
(e.g. as a father / mother)
Lost income
For society
Greater health costs
(e.g. delayed hospital discharge)
Unable to contribute to the community

27. Painful SCC (xeroderma pigmentosum)

28. Advantages of Treating Pain
For the patient
Fewer physical and psychological problems
Greater dignity (esp. cancer pain)
For the family
Able to function as part of the family
Able to provide for family
For society
Lower health costs

29. ?

30. Why Should We Treat Pain? Summary
Treating pain is the “humane” thing to do!
Treating pain has many benefits
For the patient
For the family
For society

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

33. Classification of Pain
Not all pain is the same!
Three main questions:
How long has the patient had pain?
What is the cause?
What is the pain mechanism?

34. Classification of Pain
Duration
Acute
Chronic
Acute on chronic
Cause
Cancer
Non-cancer
Mechanism
Nociceptive (physiological)
Neuropathic (pathological)

35. Acute versus Chronic Acute Chronic
Pain of recent onset and probable limited duration
Chronic
Pain persisting beyond healing of injury
Often no identifiable cause
(Pain lasting for more than 3 months)

36. 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?

37. Invasive oral cancer

38. Nociceptive Pain Obvious tissue injury or illness “Physiological pain”
Description
Sharp ± dull
Well localised
Can you give examples?

39. Neuropathic Pain Nervous system damage or abnormality
“Pathological pain”
Tissue injury may not be obvious
Description
Burning, shooting ± numbness, pins and needles
Not well localised
Can you give examples?

40. Examples of Pain Types

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

42. Chronic Non-Cancer Pain
Examples
Headache, back pain
Usually no obvious injury
Not useful
Complex, may be mixed nociceptive and neuropathic
Does not respond to usual drug treatment

43. Cancer Pain Examples Features of acute and chronic pain
Oral cancer, uterine cervical 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

44. ?

45. 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

46. Pain Physiology and Pathology
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47. Pain Physiology and Pathology Aims
To understand normal pain physiology
Pain pathway
Factors affecting the pain signal
To understand the basis of neuropathic pain(pathology)

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

49. Is this man feeling pain?

50. Nociception is not the same as pain!
03/04/10
Nociception is not the same as pain!
Injury
Beliefs/concerns about pain
Other illnesses
Psychol. factors
anxiety/anger/depression
Coping strategies
Cultural issues
Language, expectations
Social factors
e.g. family, work
Pain
What the patient says hurts.
What must be treated.
Modified from Analgesic Expert Group. Therapeutic Guidelines 2007

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

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

53. 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

54. Brain Thalamus is the “second relay station”
Connections to many parts of the brain
Cortex
Limbic system
Brainstem
Pain perception occurs in the cortex

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

56. 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.

57. Neuropathic Pain “Pathological” pain Abnormality of:
Peripheral nerves
Spinal cord or brain
Needs to be treated differently

58. Neuropathic Pain Peripheral Central
Damaged nerves (e.g. trauma, diabetes)
Abnormal firing of nerves
Central
Changes in “wiring”
Abnormal firing
Loss of modulation
How do patients describe their pain?

59. ?

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

61. Pain Treatment Overview
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62. Pain Treatment Overview Aims
To discuss non-drug and drug treatments where you work
To classify pain treatments

63. Pain Treatment Group discussion
What non-drug treatments are available where you work?
What drug treatments are available where you work?

64. Non-Drug Treatments Physical Psychological
Rest, ice, compression, elevation
Surgery
Acupuncture, massage, physiotherapy
Psychological
Explanation
Reassurance
Counseling

65. Placebo Treatment Group discussion What is placebo?
Is it helpful or unhelpful?

66. 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!

67. Drug Classification Simple analgesics Opioids
Paracetamol (acetaminophen)
Anti-inflammatory medicines
Aspirin, ibuprofen
Opioids
Mild
Codeine
Strong
Morphine, pethidine

68. Drug Classification Other analgesics Amitriptyline Carbamazepine
Local anaesthetics
Ketamine
Tramadol
Clonidine
Entonox (N2O/O2)

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

70. Treatments - Spinal Cord
Non-drug treatments
Acupuncture, massage
Local anaesthetics
Opioids
Ketamine

71. Treatments - Brain Non-drug treatments Drug treatments Psychological
Paracetamol
Opioids
Amitriptyline
Clonidine

72. ?

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

74. Pain Drugs
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75. Pain Drugs Aims
To summarise the major advantages and disadvantages of important drugs
To discuss drug addiction

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

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

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

79. Opioids and Addiction Group discussion Do opioids cause addiction?
Would this stop you giving opioids to a patient who has pain?

80. 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.

81. 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

82. Morphine 2 Disadvantages Constipation
Respiratory depression in high dose
Myths about addiction
Regulations about use

83. Pethidine Advantages Disadvantages Cheap Can be given orally, IV, IM
Can be good for severe acute nociceptive pain
Disadvantages
Must be given more often than morphine
Breakdown product (norpethidine) can cause convulsions
Not good for chronic pain

84. Amitriptyline Increases descending inhibitory signals Advantages
Cheap, safe in low dose
Good for neuropathic pain
Also treats depression, poor sleep
Disadvantages
Anti-cholinergic side effects (glaucoma, urinary retention)

85. Anti-Epileptic Drugs Carbamazepine (Tegretol)
Sodium valproate (Epilim)
“Membrane stabilisers”
Reduce abnormal firing of nerves
Good for neuropathic pain

86. Entonox (N2O/O2) Advantages Disadvantages Fast onset / fast offset
Good for:
Labour pains
Short painful procedures (e.g. dressing changes)
Disadvantages
Need cylinder and mask

87. Drug Treatments +++ ++ + ± - Acute noci mild Acute noci severe
Acute neuro
Chronic non-cancer
Chronic cancer
Paracetamol
+++ ++ +
NSAIMs
Codeine
Morphine -
Amitriptyline
Carbamazepine

88. ?

89. Pain Drugs Summary
Pain can be treated with relatively cheap and safe drugs.
Opioid addiction is rare in acute or cancer pain.

90. Barriers to Pain Treatment
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91. Barriers to Pain Treatment Aims
To understand some of the reasons why pain may not be treated adequately
To think about some solutions

92. Barriers to Pain Treatment
Group Discussion
Pain is often not treated as well as it could be. What are some of the reasons for this?
Patients
Drugs
Health workers
System issues
What are the main barriers where you work?
What can be done about these barriers?

93. ?

94. Barriers to Pain Treatment Summary
There are many reasons why pain is not treated as well as it could be.
Important barriers are attitudes, lack of staff and lack of drugs.
How can YOU overcome these barriers where you work?

95. Basic Approach to Pain Management
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96. Basic Approach Aims
To give a simple framework for managing patients with pain
To illustrate the use of this framework for different types of pain

97. Approach to Pain

98. Approach to Pain
Recognize
Assess
Treat

99. Approach to Pain 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

100. Approach to Pain Assess
Measure 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?

101. Measuring Pain 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

102. Visual Analogue Scale

103. Faces Pain Scale

104. Approach to Pain Assess
Make a pain diagnosis!
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)

105. Approach to Pain Assess
Are there other factors?
Physical factors (other illnesses)
Psychological and social factors
Anger, anxiety, depression
Lack of social supports

106. Approach to Pain Treat Non-Drug Treatments RICE Nursing care
Rest, ice, compression, elevation of injuries
Nursing care
Surgery, acupuncture, massage etc
Psychological
Explanation and reassurance
Input from social worker / pastor

107. Approach to Pain Treat Drug Treatments – Nociceptive Pain Mild
Paracetamol (± NSAIM)
Moderate
Paracetamol (± NSAIM) + codeine
Severe
Paracetamol (± NSAIM) + morphine

108. Approach to Pain Treat Drug Treatments – Neuropathic Pain
Traditional drugs may not be as useful
Use other drugs early
Amitriptyline
Carbamazepine
Don’t forget non-drug treatments

109. Approach to Pain Example 1
Mr D is a 32-year-old man who caught his right hand in a piece of machinery at work and now has a large open wound with several broken bones.
How would you manage his pain?

110. Approach to Pain Example 2
Jon is an 8-year-old boy with probable appendicitis. He is in the Emergency Department and will have to wait several hours for an operation.
How would you manage his pain?

111. Approach to Pain Example 3
Miss B is a 24-year-old woman who has a two year history of severe headache. She was seen at the regional hospital 6 months ago and was told that there was “nothing wrong inside her head” and she was going to have to live with the pain.
How would you manage her pain?

112. Approach to Pain Example 4
Maria is a 12-year-old girl with burns to her chest and abdomen. She needs dressing changes every 2-3 days.
How would you manage her pain?

113. ?

114. Approach to Pain Summary
Recognize
Assess
Measure severity
Make a pain diagnosis
Consider other factors
Treat
Non-drug treatments
Drug treatments