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

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

21/10/20093

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

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

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);

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.

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.

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.

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

21/10/ 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

21/10/ 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

21/10/ 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.

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

21/10/ 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.

21/10/ 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.

21/10/ 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.

21/10/ 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

21/10/  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.

21/10/ 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)

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

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

21/10/ FACTORS INFLUENCING PAIN PHYSIOLOGICAL SOCIAL SPIRITUAL PSYCHOLOGICAL CULTURAL

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

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

BOX 8-2 (continued) ASSESSMENT

21/10/ 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.

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

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

21/10/ 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

21/10/ 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

21/10/ 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

21/10/ Pain Treatment

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

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

21/10/ VAS vs WHO VAS WHO Steps Step 1 Step 2 Step 3

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

21/10/ 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

21/10/ 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.

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

21/10/ 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

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

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

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