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

2. 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

3. 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 , Mersky, Bogduk
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.

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

5. 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.

6. 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.

7. 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

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

9. 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.

10. Nociception - The Process

11. 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.

12. 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.

13. 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!

14. 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.

15. 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).

16. 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.

17. 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.

18. 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.

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

20. References
Fanciullo, G, (2000). Acute Pain Management , Symposium Spotlight: The 16th Annual Meeting of the American
Academy of Pain Medicine, New Orleans, La., Feb
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