1. 21/10/20091 Pain Management What is it? Dr Ibraheem Bashayreh, RN, PhD

2. 21/10/20092 Pain… What is the real definition of pain? And what is pain management?? How can this information help me???

3. 21/10/20093

4. 4 Pain Definitions: An unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is whatever the experiencing person says it is. May not be directly proportional to amount of tissue injury. Highly subjective, leading to undertreatment

5. 21/10/20095 Classification of Pain 1.Acute 2.Cancer 3.Chronic non-malignant

6. 21/10/20096 Acute Pain Injury, trauma, spasm or disease to skin, muscle, somatic structures or viscera; Perceived and communicated via peripheral mechanisms (pathways) A delta and C fibers Usually with autonomic response as well (tachycardia,­ blood pressure, diaphoresis, pallor, mydriasis (pupil dilation);

7. 21/10/20097 Acute Pain Usually subsides quickly as pain producing stimuli decreases Associated with anxiety-(decreases rapidly) Can be understood or rationalized as part of the healing process.

8. 21/10/20098 Chronic Pain Non-malignant Pain persists beyond the precipitating injury Rarely accompanied by autonomic symptoms Sufferers often fail to demonstrate objective evidence of underlying pathology. Characterized by location-visceral, myofacial, or neurologic causes.

9. 21/10/20099 Chronic Pain Malignant Has characteristics of chronic pain as well as symptoms of acute pain (breakthrough pain). Has a definable cause, e.g. tumor recurrence In treatment, narcotic habituation isgenerally not a concern.

10. 21/10/200910 Types of Pain Somatic Visceral Referred Bone Neuropathic Emotional/Spiritual

11. 21/10/200911 Somatic Pain Aching, often constant May be dull or sharp Often worse with movement Well localized Skin, Muscle, Joints, superficial or deep. Eg: – Bone & soft tissueBone – chest wall

12. 21/10/200912 Visceral Pain Constant or crampy Aching, burning Poorly localized Referred Organs of Thorax & Abdominal Cavity. Usually as a result of stretching, infiltration and compression Eg/ – CA pancreas – Liver capsule distension – Bowel obstruction

13. 21/10/200913 Types of Pain Both Somatic & Visceral pain travel along the same pathways. Pain stimuli arising from the viscera is perceived as somatic in origin. This can be confused by the brain and is often described as referred pain.

14. 21/10/200914 Liver Small Intestine Appendix Right Ureter Liver Heart Stomach Gallbladder Ovary Colon Kidney Bladder

15. 21/10/200915 Types of Pain Bone Pain Poorly localised, aching, deep, burning. Common with Breast, Lung, Prostate, Bladder, Cervical, Renal, Colon, Stomach and Oesophagus Can lead to pathological fractures. Vertebral Metastases can lead to cord compression.

16. 21/10/200916 Bone Pain Osteoblasts, Osteoclasts and Osteocytes are involved in remodelling bone. In healthy individuals bone remodelling is carefully regulated. Normally Osteoblasts replace the same amount of bone which has been resorbed by the Osteoclasts. In malignancy process not balanced, resulting in a loss of bone mass.

17. 21/10/200917 Types of Pain Neuropathic Pain Caused by disturbance of function or pathological changes in a nerve. May arise from a lesion or trauma, infection, compression or tumour invasion. Described as burning, shooting, tingling. Does not respond well to standard analgesics.

18. 21/10/200918 Neuropathic Pain Abnormal Sensations Hyperaesthesia - an increased sensitivity to stimulation. Hyperalgesia – increased response to a stimulus that is normally painful. Allodynia – pain caused by a stimuli that is not normally painful

19. 21/10/200919  Neuralgia Pain in the distribution of the nerve, lancing, shooting, jumping, electricity.  Parasthesia An abnormal sensation, tingling, pins and needles.  Tight Feeling Vice like tightness, gripping, cramping.

20. 21/10/200920 Major Categories of Pain Classified by inferred pathophysiology: 1. Nociceptive pain (stimuli from somatic and visceral structures) 2. Neuropathic pain (stimuli abnormally processed by the nervous system)

21. 21/10/200921 Effects of pain Sympathetic responses Pallor Increased blood pressure Increased pulse Increased respiration Skeletal muscle tension Diaphoresis

22. 21/10/200922 Effects of pain Parasympathetic responses Decreased blood pressure Decreased pulse Nausea & vomiting Weakness Pallor Loss of consciousness

23. 21/10/200923 FACTORS INFLUENCING PAIN PHYSIOLOGICAL SOCIAL SPIRITUAL PSYCHOLOGICAL CULTURAL

24. 21/10/200924 Pain Assessment Pain History The site of pain Type of pain Exacerbating & Relieving factors How frequently Impact on daily life Previous therapies

25. 21/10/200925 Pain Assessment Factors to Consider Mood Non Verbal Communication Environment Ethnicity

27. BOX 8-2 (continued) ASSESSMENT

28. 21/10/200928 Concerns & Misconceptions Pain is inevitable. If the pain is worse, my cancer is spreading. I should wait until I really need my pain killer, before I take it. If I take Morphine I will die soon. I will get addicted to pain killers.

29. 21/10/200929 PAIN ASSESSMENT Tools PAIN RATING SCALES- NRS, VAS,VAT,FACES RATING SCALE, PAIN-0-METER McGill PAIN QUESTIONNAIRE BODY MAP

30. 21/10/200930 Severity Assessment McGill Pain Questionnaire 0 ----------> 5 None -------------------> Excruciating Mild, Discomforting, Distressing, Horrible, in between. (for children or adults who understand numerical relationships)

31. 21/10/200931 ABCDE for pain assessment &management Ask about pain regularly Believe the patient and family in their reports &what relieves it Choose pain control options appropriate for the patient Deliver interventions timely, logical &coordinated fashion Empower patient and their families

32. 21/10/200932 JCAHO Standards for postoperative pain management are: Recognize patients’ rights to appropriate assessment and management of pain Screen for pain and assess the nature and intensity of pain in all patients Record assessment results in a way that allows regular reassessment and follow-up Determine and ensure that staff are competent in assessing and managing pain. Address pain assessment and management when orienting new clinical staff

33. 21/10/200933 Standards Contd.. Establish policies and procedures that support appropriate prescribing of pain medications Ensure that pain doesn’t interfere with a patient’s participation in rehabilitation Educate patients and their families about effective pain management

34. 21/10/200934 Pain Treatment

35. 21/10/200935 +/- adjuvant Non-opioid Weak opioid Strong opioid Pain persists or increases By the Clock, Mouth WHO Pain Management Ladder +/- adjuvant 1 2 3

36. 21/10/200936 WHO Pain Management Ladder Step 1 NSAIDS, + adjuvants Step 2 NSAID + mild opioids + adjuvant Step 3 strong opioids + NSAIDS + adjuvants

37. 21/10/200937 VAS vs WHO VAS 1 - 3 4 - 6 7 - 10 WHO Steps Step 1 Step 2 Step 3

38. 21/10/200938 Non-opioid e.g. aspirin, paracetamol Opioid e.g. codeine, morphine Adjuvant e.g. muscle relaxant, antidepressant, anti-epileptic Analgesics

39. 21/10/200939 Opioid Side Effects Constipation – need proactive laxative use Nausea/vomiting – consider treating with dopamine antagonists and/or prokinetics (metoclopramide, domperidone, prochlorperazine [Stemetil], haloperidol) Urinary retention

40. 21/10/200940 Opioid Side Effects Itch/rash – worse in children; may need low-dose naloxone infusion. May try antihistamines, however not great success Dry mouth Respiratory depression – uncommon when titrated in response to symptom Drug interactions Neurotoxicity (OIN): delirium, myoclonus  seizures.

41. 21/10/200941 Management contd.. Non-pharmacological interventions Massage Diversion therapy Relaxation therapy Heat & cold applications Yoga

42. 21/10/200942 Summary Pain is a subjective experience and is influenced by many factors not just physical processes The WHO pain ladder is recommended Introduce drug therapy in stepwise manner, matching the initial analgesic to the level and type of pain Other interventions, drug and non drug should be considered

43. 21/10/200943 “Pain is a more terrible lord of mankind than death itself.” Albert Schweitzer

44. 21/10/200944 When the music changes, so must the dance…. African Proverb

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