12Introduction Summary At the end of this course, you will be able to: Understand the importance of treating painRecognize, assess and treat different types of painIdentify and address barriers where you work
13What is Pain?CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License.
14What is Pain? AimsTo define painTo give examples of pain
15What is Pain? Group discussion Think of a patient / friend / relative who had pain.How did the person describe the pain?How was it treated?
16What 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?
17What is Pain? Unpleasant Emotions are important The cause is not always visible“Pain is what the patient says hurts.”
20What is Pain? SummaryPain is an unpleasant sensory and emotional experiencePain is what the patient says hurts!
21Why Should We Treat Pain? CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License.
22Why Should We Treat Pain? Aims To understand the reasons for treating painTo understand the benefits for the patient, family and society
23Case 1Mr 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 8Why should we treat his pain?
24Case 2Mrs 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?
25Why Pain Matters For the patient Physical Psychological Suffering, poor sleep, decreased appetiteMedical complications(e.g. heart attack, pneumonia)PsychologicalDepression, anxiety
26Why Pain Matters For the family For society Unable to function as part of the family(e.g. as a father / mother)Lost incomeFor societyGreater health costs(e.g. delayed hospital discharge)Unable to contribute to the community
28Advantages of Treating Pain For the patientFewer physical and psychological problemsGreater dignity (esp. cancer pain)For the familyAble to function as part of the familyAble to provide for familyFor societyLower health costs
38Nociceptive Pain Obvious tissue injury or illness “Physiological pain” DescriptionSharp ± dullWell localisedCan you give examples?
39Neuropathic Pain Nervous system damage or abnormality “Pathological pain”Tissue injury may not be obviousDescriptionBurning, shooting ± numbness, pins and needlesNot well localisedCan you give examples?
41Acute Non-Cancer Pain Examples Symptom of tissue injury or illness Fracture, appendicitisSymptom of tissue injury or illnessUsefulUsually nociceptiveOccasionally neuropathic (e.g. sciatica)
42Chronic Non-Cancer Pain ExamplesHeadache, back painUsually no obvious injuryNot usefulComplex, may be mixed nociceptive and neuropathicDoes not respond to usual drug treatment
43Cancer Pain Examples Features of acute and chronic pain Oral cancer, uterine cervical cancerFeatures of acute and chronic painMay be acute on chronicOften mixed nociceptive and neuropathic painUsually gets worse over time if untreated
50Nociception is not the same as pain! 03/04/10Nociception is not the same as pain!InjuryBeliefs/concerns about painOther illnessesPsychol. factorsanxiety/anger/depressionCoping strategiesCultural issuesLanguage, expectationsSocial factorse.g. family, workPainWhat the patient says hurts.What must be treated.Modified from Analgesic Expert Group. Therapeutic Guidelines 2007
51Physiology 4 steps: We will look at each step Periphery Spinal cord BrainModulationWe will look at each step
52Periphery Tissue injury Release of chemicals Stimulation of pain receptors (nociceptors)Signal travels in Aδ or C nerve to spinal cord
53Spinal Cord Dorsal horn is the “first relay station” Aδ or C nerve synapses (connects) with second nerveSecond nerve travels up opposite side of spinal cord
54Brain Thalamus is the “second relay station” Connections to many parts of the brainCortexLimbic systemBrainstemPain perception occurs in the cortex
55Modulation Descending pathway from brain to dorsal horn Usually decreases pain signal
56Why 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.
57Neuropathic Pain “Pathological” pain Abnormality of: Peripheral nervesSpinal cord or brainNeeds to be treated differently
58Neuropathic Pain Peripheral Central Damaged nerves (e.g. trauma, diabetes)Abnormal firing of nervesCentralChanges in “wiring”Abnormal firingLoss of modulationHow do patients describe their pain?
60Pain 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.
61Pain Treatment Overview CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License.
62Pain Treatment Overview Aims To discuss non-drug and drug treatments where you workTo classify pain treatments
63Pain Treatment Group discussion What non-drug treatments are available where you work?What drug treatments are available where you work?
73Pain 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.
74Pain DrugsCC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License.
75Pain Drugs AimsTo summarise the major advantages and disadvantages of important drugsTo discuss drug addiction
76Paracetamol (Acetaminophen) AdvantagesCheap, safeCan be given orally or rectallyGood for:Mild pain (by itself)Mod-severe pain (with other drugs)DisadvantagesLiver damage in overdose
77Anti-Inflammatory Medicines Aspirin, ibuprofenAdvantagesCheap, generally safeGood for nociceptive painBest given regularly with paracetamolDisadvantagesGastrointestinal and renal side effects
78Codeine Advantages Disadvantages Cheap, safe Good for mild-moderate acute nociceptive painBest given regularly with paracetamolDisadvantagesConstipationNot good for chronic painMyths about addiction
79Opioids and Addiction Group discussion Do opioids cause addiction? Would this stop you giving opioids to a patient who has pain?
80Opioids and AddictionPain is sometimes poorly treated because of concerns about addiction.Addiction is very rare in:Acute painCancer painAddiction is more likely in chronic non-cancer pain.
81Morphine 1 Advantages Cheap, generally safe Can be given orally, IV, IM, SCEffective if given regularlyGood for:Mod-severe acute nociceptive pain (e.g. post-op pain)Chronic cancer pain
82Morphine 2 Disadvantages Constipation Respiratory depression in high doseMyths about addictionRegulations about use
83Pethidine Advantages Disadvantages Cheap Can be given orally, IV, IM Can be good for severe acute nociceptive painDisadvantagesMust be given more often than morphineBreakdown product (norpethidine) can cause convulsionsNot good for chronic pain
84Amitriptyline Increases descending inhibitory signals Advantages Cheap, safe in low doseGood for neuropathic painAlso treats depression, poor sleepDisadvantagesAnti-cholinergic side effects (glaucoma, urinary retention)
85Anti-Epileptic Drugs Carbamazepine (Tegretol) Sodium valproate (Epilim)“Membrane stabilisers”Reduce abnormal firing of nervesGood for neuropathic pain
86Entonox (N2O/O2) Advantages Disadvantages Fast onset / fast offset Good for:Labour painsShort painful procedures (e.g. dressing changes)DisadvantagesNeed cylinder and mask
87Drug Treatments +++ ++ + ± - Acute noci mild Acute noci severe Acute neuroChronic non-cancerChronic cancerParacetamol++++++NSAIMsCodeineMorphine-AmitriptylineCarbamazepine
89Pain Drugs SummaryPain can be treated with relatively cheap and safe drugs.Opioid addiction is rare in acute or cancer pain.
90Barriers to Pain Treatment CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License.
91Barriers to Pain Treatment Aims To understand some of the reasons why pain may not be treated adequatelyTo think about some solutions
92Barriers to Pain Treatment Group DiscussionPain is often not treated as well as it could be. What are some of the reasons for this?PatientsDrugsHealth workersSystem issuesWhat are the main barriers where you work?What can be done about these barriers?
94Barriers 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?
95Basic Approach to Pain Management CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License.
96Basic Approach AimsTo give a simple framework for managing patients with painTo illustrate the use of this framework for different types of pain
104Approach to Pain Assess Make a pain diagnosis!Acute or chronic?Cancer or non-cancer?Nociceptive or neuropathic?Look for neuropathic features:Burning or shooting painPhantom limb painOther features (pins and needles, numbness)
105Approach to Pain Assess Are there other factors?Physical factors (other illnesses)Psychological and social factorsAnger, anxiety, depressionLack of social supports
106Approach to Pain Treat Non-Drug Treatments RICE Nursing care Rest, ice, compression, elevation of injuriesNursing careSurgery, acupuncture, massage etcPsychologicalExplanation and reassuranceInput from social worker / pastor
108Approach to Pain Treat Drug Treatments – Neuropathic Pain Traditional drugs may not be as usefulUse other drugs earlyAmitriptylineCarbamazepineDon’t forget non-drug treatments
109Approach 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?
110Approach 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?
111Approach 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?
112Approach 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?