Pain as The 5th Vital Sign Guideline: 3rd Edition

This document was developed by the Clinical Audit Unit, Medical Care
Quality Section of Medical Development Division, Ministry of Health
Malaysia and the National Pain Free Programme Committee.

Published in September 2018

A catalogue record of this document is available from the National Library

of Malaysia
ISBN: 978-967-2173-31-1

A copy of this document is also available at MOH Portal: www.moh.gov.my

Copyright © Ministry of Health Malaysia.

All rights reserved. No part of this publication may be reproduced or
distributed in any form or by any means or stored in a database or
retrieval system without prior written permission from the Ministry of
Health Malaysia.

2
FOREWORD

Pain is one of the most common reasons why patients

seek medical treatment, and yet many patients still suffer
in pain. Pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage. Pain is not just a physical sensation, but it is also
influenced by attitudes, beliefs, personality and social
factors, and it can affect emotional and mental wellbeing.

Realizing how pain can affect our patients’ experience, proper pain
assessment in the Ministry of Health (MOH) healthcare facilities is deemed
crucial in ensuring our patients receive adequate pain management.
Improving pain assessment, hence, is an important strategy to improve pain
management. The “Pain as the 5th Vital Sign” initiative was initiated by the
Ministry of Health in 2008 with the objective of ensuring the patient’s pain
is being addressed effectively and up until now, the objective remains the
same.

The most essential part of the implementation of this initiative is the

continuous training of healthcare providers, specifically in pain assessment
and management. This book provides a standardized training module for
paramedics and doctors to refer to when necessary. I would like to
congratulate and thank the editorial team for their hard work in publishing
this guideline. I sincerely hope that all MOH staff will use these guidelines
to ensure the proper pain assessment and management of pain are being
carried out to deliver the best quality of care to patients.

Dato’ Dr. Azman bin Abu Bakar

Deputy Director-General of Health
Ministry of Health Malaysia

3
PREFACE

This book is a revision of the 2nd Edition of the Pain as the 5th Vital Sign
booklet published in 2013. It consists of Guideline for Paramedics:
Management of Pain in Adult Patients, and Guideline for Doctors:
Management of Pain in Adult Patients. The content was reviewed and
updated in accordance with the recent development of Pain Management
in Malaysia. This book includes basic information on pain assessment and
management for the Paramedics and Doctors. It is our greatest hope that
this book will be a useful resource for Ministry of Health staff in ensuring
the best quality of care, especially in pain management, is deliver to our
patients.

National Pain Free Programme Committee

2018

CONTRIBUTORS

1. Dr. Mary S. Cardosa

2. Dr. Ungku Kamariah Ungku Ahmad
3. Dr. Ng Kim Swan
4. Dr. Kavitha Bhojwani
5. Dr. Aminuddin Ahmad
6. Dr. Harijah Wahidin
7. Dr. Muralitharan Perumal
8. Dr. Paa Mohamed Nazir Abdul Rahman
9. Dr. Faizah Muhamad Zin
10. Dr. Anith Syazwani Adnan
11. Dr. Nur Mastura Aliyasaa’
12. Nursing Division MOH

4
CONTENT

Part 1: Guidelines for Paramedics: Management of Pain in Adult Patients

1.1 Introduction 8
1.2 Objectives 9
1.3 Definition of Pain 10
1.4 Types of Pain 10
1.5 Effects of Acute Pain 10
1.6 Pain Assessment 11
Why Pain Assessment?
When should Pain be assessed?
Who should do Pain Assessment?
Which Pain Assessment Tool to use
How to use Pain Assessment Tool?
Taking Pain History
Body Chart to show pain sites
1.7 What is the next step after Pain Assessment? 14
Examples of nursing action and other non-pharmacological techniques
1.8 Summary and Conclusion 16
1.9 References 17

Appendix 1.1a FLACC Scale

Appendix 1.1b Skala FLACC
Appendix 1.2 IASP Faces Scale
Appendix 1.3 Example of Pain Assessment Chart
Appendix 1.4 Flow Chart for Pain Management in Adult Patients in Hospitals
(paramedics)
Appendix 1.5 Flow Chart for Pain Management in Adult Patients in Primary Care
(paramedics)

5
Part 2: Guidelines for Doctors: Management of Pain in Adult Patients

2.1 Introduction 25
2.2 Definition of Pain 25
2.3 Classification of Pain 25
Types of Pain
Differences between acute and chronic pain
Differences between nociceptive and neuropathic pain
2.4 Adverse effects of unrelieved severe acute pain 28
2.5 Pain Physiology 28
2.6 Pain Assessment 30
Pain Assessment tools
When should pain be assessed?
2.7 Management of Acute Pain 32
Non-pharmacological approach
Pharmacological approach
Placebo
Analgesic strategies
Analgesic ladder for acute pain
Intravenous morphine pain protocol
2.8 The R-A-T Approach to Pain Management 34
Recognize
Assess
Treat
2.9 Management of Side effects 36
Nausea and vomiting
Respiratory depression
2.10 References 38

Appendix 2.1 Notes on Analgesic Medication

Appendix 2.2 Flow Chart for Pain Management in Adult Patient in Hospitals
(Doctors)
Appendix 2.3 Flow Chart for Pain Management in Adult Patient in Primary Care
(Doctors)
Appendix 2.4 Analgesic Ladder for Acute Pain Management
Appendix 2.5 IV Morphine Pain Protocol
Appendix 2.6 Sedation Score
Appendix 2.7 Principles of Management of Chronic non-cancer pain

6
Management of Pain in Adult Patients
Guidelines for PARAMEDICS

7
1.1 INTRODUCTION

• Pain is a common symptom experienced by many patients. Patients often have

to tolerate severe pain due to poor pain management.

• Poor pain management in patients is due to:

o Ignorance
o Inexperience
o Overwork
o Traditional fears related to opioids, including fear of addiction and fear of
side effects like respiratory depression
o Failure of patients to ask for pain relief

• Recognition and Assessment of pain are important aspects in patient care that
we need to seriously undertake in order to make sure patients are comfortable.

• Pain is very subjective and the patient’s self-report is the gold standard in the
measurement of pain.

• Healthcare professionals should not just guess what the patient’s pain level is;
rather, we should ask the patient and believe the patient’s report.

• Do not ignore patients complain of pain.

• Patients’ pain should be recognized, assessed and treated adequately to:

o Promote holistic patient-centered care
o Facilitate rapid recovery and discharge
o Reduce post-operative morbidity

• When patients complain of pain, healthcare providers need to act and evaluate
the results of this action. Paramedics are often the first to have to attend to
patients in pain and nursing action can make a big difference to a patient in pain.

• An action may not necessarily be administering analgesics. There are many non-
pharmacological techniques which can relieve pain, e.g. repositioning the patient
to make him/her more comfortable. You will then need to reassess the patient
to check the effectiveness of your action and to decide whether analgesic
medication or other treatment is required.

8
• “Pain as the 5th Vital Sign” brings about multiple benefits to the patients, and to
the organization. Importantly it promotes paramedics-patient interaction,
doctor-patient interaction and client satisfaction. It also incorporates the 10 ‘S’
as recommended by the Nursing Division, Ministry of Health Malaysia.

10 ‘S’
Salam / Greet
Senyum / Smile
Sopan / Well mannered
Sensitif / Sensitive
Segera / Immediately
Sentuh / Touch
Segak / Professional
Selia / Supervise
Semangat / Motivated
Selidik / Study & audit

1.2 OBJECTIVES

“Pain as the 5th Vital Sign” was launched by the Ministry of Health (MOH) in 2008
as one of the strategies to enhance the pain services in the country.

The objective of this module is to train paramedics in order to implement Pain as

the 5th Vital Sign effectively in MOH hospitals, thus meeting the objectives of the
“Pain Free Hospital” concept proposed by the MOH in 2011 and primary healthcare
in 2015, by:

- improving the understanding of pain

- teaching a simple framework of pain assessment and pain management

Specific objectives of this module are to enable paramedics to:

i. Define pain and describe types of pain.
ii. Undertake a comprehensive assessment of pain in your patients.
iii. Use pain assessment tools effectively.
iv. Assess patients’ pain level effectively.
v. Identify and carry out appropriate interventions in pain management.
vi. Involve patients in their pain management.

9
1.3 DEFINITION OF PAIN

Pain is defined as “an unpleasant sensory and emotional experience associated

with actual or potential tissue damage or described in terms of such damage”.
Merskey and Bogduk, International Association for the Study of Pain (IASP) 1994.

1.4 TYPES OF PAIN

• Acute pain – pain associated with tissue injury e.g. pain after surgery, fracture,
burns, inflammation, etc.

o Nociceptive somatic pain is usually well localized, described as sharp,

aching or throbbing, often worse on movement.
o Visceral pain is usually poorly localized; described as deep, cramping,
gnawing or colicky.

• Chronic pain – pain lasting for more than 3 months or pain that persists after
the injury has healed.

o May be nociceptive (somatic or visceral) or neuropathic.

o Neuropathic pain is pain resulting from injury to the central or peripheral

nervous system and is often described as burning, shooting, stabbing; it
may be associated with numbness, tingling or other sensory changes.

o Includes chronic cancer pain.

1.5 EFFECTS OF ACUTE PAIN

I. Restricts movement
II. Disturbs sleep/ rest
III. Restricts activities e.g. ADLs
IV. Affects emotions and relationships, e.g. patient may be depressed, anxious,
irritable
V. Adverse physiological effects on various systems:
a. Cardiovascular system: increased HR, BP → increased stress on heart
b. Respiratory system: reduced cough, cannot take deep breaths →
increased risk of pneumonia, hypoxia
c. Endocrine system: increased stress hormones
d. Gastrointestinal system: ileus

10
PAIN ASSESSMENT

Why pain assessment?

• To ensure patients in pain receive adequate pain relief with minimal side
effects.

When should pain be assessed?

• At regular intervals – as the 5th vital sign during routine observation of other
vital signs i.e. BP, heart rate, respiratory rate and temperature. This can be 4-
hour interval or upon any specific orders.
• On admission of patient.
• On transfer-in of patient.
• At other times apart from scheduled observations:
- Half to one hour after administration of analgesics and nursing
intervention.
- During and after any painful procedure in the ward e.g. wound dressing.
- Whenever the patient complains of pain.
• Pain should not be assessed only at rest but also on movement and with
function e.g. coughing and deep breathing.

Who should do pain assessment?

• All paramedicss
• All Doctors
• All Student paramedicss
• All medical students
….. Everyone

Which pain assessment tool to use?

There are many pain assessment tools available, including:

• Numerical Rating Scale (NRS) - 0 to 10
• Visual Analogue Score (VAS) - a mark made on a line 100 mm long
• Categorical Score – mild/ moderate/ severe
• Functional Score – ability to walk, sit, cough etc.
• FLACC Observational Pain Score
• IASP Faces Scale

11
The pain assessment tool that is recommended for use in our hospitals is the Ministry of
Health (MOH) pain scale as shown below. This is used in adults and in children more than
7 years old.

Figure 1.6.1 MOH Pain Scale

The MOH pain scale is a scale that combines NRS, the VAS and faces scale. The patient is
asked to indicate his/ her level of pain intensity by pointing along a scale. The scale has
numbers and the pain score is recorded as a number from 0 to 10.

In children less than 7 years old and cognitively impaired adults, other scales like IASP
Faces Scale or FLACC scale can be used. In patients who are sedated and intubated, pain
assessment will rely on observations and behavioral assessment.

Figure 1.6.2 MOH Face Scale

Figure 1.6.3 FLACC Scale

12
How to use the pain assessment tool?

• Greet patient.
• Inform the purpose: to get the patient’s correct pain score for proper treatment
• Show patient the pain assessment tool and teach him/her how to use it, e.g.
using the MOH Pain scale, ask the patient:

“If ‘0’ is no pain and ‘10’ is the worst pain you can imagine, what number would
you give your pain now?”

• Give patient time to think and give the pain score – be patient!
• Always use the same pain scale for the same patient.

Note: Record ‘Unable to Score’ for patients who are unconscious or unable to
give a pain score for other reasons.

Taking the Pain History and Documentation in Pain Assessment Form

At the first contact, the paramedic should start by taking the pain history.

I. Ask the patient: listen and believe the patient’s complaint of pain.

The pain history may be taken using the acronym P A I N:

o P: Place or site of pain

o A: Aggravating factors (“What makes the pain worse?”)
o I : Intensity
o N: Nature (“What does the pain feel like?”)
Neutralizing factors (“What makes the pain better?”)

II. In the first assessment you should mark the pain site(s), and record the
date, pain score and nature of pain on the body chart. In subsequent
observations, only pain scores are taken and recorded in the pain
assessment chart (refer Appendix 1.4).

III. If the patient reports a new pain in a different site not previously
recorded, record the new pain site in the body chart as well.

13
Figure 1.6.4 illustrates how to chart the pain sites and their characteristics on the
body chart.

Figure 1.6.4: Body chart to show pain sites. !

1.6 WHAT IS THE NEXT STEP AFTER PAIN ASSESSMENT?

Follow the Flow Chart for Pain Management in Adult patients in Hospital (refer
Appendix 1.5) or primary healthcare (refer Appendix 1.6).

Pain score < 4:

Ask the patient if she/ he is comfortable and whether she/ he would like you to
do anything (nursing action/ simple analgesics like paracetamol).
Usually no action is required.
Record the pain score.

14
Pain score > 4:
• Provide non-pharmacological techniques which can reduce pain (refer Table
1.7.1).
• Check the patient’s notes.
o If analgesics are not ordered, inform the doctor to order analgesics
and serve the medication.
o If analgesics are ordered, check when the last dose of analgesic was
given
▪ If opioids given more than 1 hour ago, you may serve another
dose after a discussion with doctor.
▪ If no opioids ordered, inform doctor
• Reassess the pain (take another pain score) after 30 minutes-1hour
o If pain score is < 4, record the pain score.
o If pain score still > 4, inform the doctor.

If the patient is already under the care of the Acute Pain Service (APS):
• Check the equipment (e.g. PCA pump or epidural infusion).
• Check to see that there is still medication in the syringe/ cassette.
• If the patient is on PCA, check that she/ he understands how to use the PCA.
• Inform the APS.

Table 1.7.1 Examples of nursing action and other non-pharmacological techniques for
pain management.
Action
Check possible causes of pain - Blocked urinary catheter
- Swollen intravenous site
- Uncomfortable position of patient

Reassurance - Explanation about the cause of the pain

- Information about the analgesia that you
are going to give
Relaxation techniques - Deep Breathing
- Meditation

Topical application - Heat therapy

- Ice / cold pack / cryotherapy

Touch therapy - Massage/ soft tissue manipulation

Distraction techniques - Reading

- Listening to music / radio
- Watching TV

15
1.8 SUMMARY AND CONCLUSION

Pain as the 5th Vital Sign is necessary to ensure patients have a pleasant and
comfortable stay in the hospital. We must be very positive and implement pain
assessment as diligently as we do for the other 4 vital signs of blood pressure, pulse,
respiratory rate and temperature.

Pain as 5th Vital Sign promotes paramedics-patient interaction and client

satisfaction, as well as reduces length of stay, morbidity and health care costs. It is
beneficial to the patient, the organization and everyone in the medical profession.
Regular pain assessment therefore should be made a culture in nursing just as for
the other 4 vital signs.

A Ask patients pain level regularly.

Assess pain systematically.

B Believe patient’s pain level.

Believe patient’s family on effective pain relief method.

C Choose pain control option appropriate for the patient and setting.

D Deliver intervention timely, logically and in a coordinated fashion.

E Empower patient and family in pain management.

ABCD of Pain Management & Pain Assessment (Jacox et al. 1992)

ROLES & RESPONSIBILITY OF PARAMEDICS

FOR EFFECTIVE PAIN MANAGEMENT

Know how to use the pain assessment tool

Carry out pain assessment
Give Prompt nursing action
Provide Prompt pain relief
Observe for side effects of analgesics
Reassess after 30 mins to 1 hour
Record pain score in the Observation Chart
Monitor patient’s pain regularly
Educate patient & family on pain assessment / treatment
Record all observations and action

16
1.9 REFERENCES

1. Pekeliling Ketua Pengarah Kesihatan Bilangan 9 Tahun 2008.: Pelaksanaan

Tahap Kesakitan Sebagai Tanda Vital Kelima (Pain as Fifth Vital Sign) di
Hospital-hospital Kementerian Kesihatan. Bahagian Perkembangan Perubatan,
Kementerian Kesihatan Malaysia, 2008.
2. Camppeu D. et al 2003: Review of Acute Pain Management in Victoria.
Available at: www.health.vic.gov.au
3. Griffie, McKinnon, Berry, & Heidrich, 2002
4. Joint Commission on Accreditation of Healthcare Organizations (2003). 2003
Hospital Accreditation Standards. Effective January 1, 2001. Available at:
www.jcaho.org/newsroom/healthcare
5. Jacox et.al.1992: ABCD of Pain Management & Pain Assessment.
6. Merskey H & Bogduk N. Classification of Chronic Pain. 2 ed. Seattle:
International Association for the Study of Pain; 1994.
7. Wendler R. Pain: The Fifth Vital Sign. Hospitals Adopt New Pain Management
Measures, Texas Medical Center News, Vol. 23, No. 1
8. Wong D, Baker C 1988. Pain in children: Comparison of assessment scales.
Pediatric Nursing 14:9-17.

17
Appendix 1.1a FLACC Scale

This is an observational score, and is used for paediatric patients aged >1 month to 3
years. It may also be used in adult patients who are unable to communicate verbally, e.g.
very elderly patient, cognitively impaired patient.

1. Observe behaviour
2. Select a score according to behaviour
3. Add the scores for the total

Each of the five categories (F) face, (L) legs, (A) activity, (C) cry and (C) consolability is
scored from 0-2, resulting in total range of 0-10

Scoring
Category
0 1 2
Occasional grimace or Frequent to constant
No particular
Face frown, withdrawn, quivering chin,
expression or smile
disinterested clenched jaw
Legs Normal position or Kicking or legs drawn
Uneasy, restless, tense
relaxed up
Arched, rigid or jerking
Lying quietly, normal Squirming, shifting
Activity
position, moves easily back and forth, tense

Crying steadily,
No cry (awake or Moans or whimpers;
Cry screams or sobs,
asleep) occasional complaint
frequent complaints
Reassured by
occasional touching,
Consolability Content, relaxed Difficult to console
hugging or being
talked to, distractible

18
Appendix 1.1b SKALA FLACC
TRANSLATION OF FLACC SCALE IN BAHASA MALAYSIA
*This is for reference only and not to be used in pain measurement as it is not a validated
version.

Skala FLACC: Skala permarkahan ini adalah untuk diaplikasikan kepada kanak-kanak
kurang dari 3 tahun atau pesakit lain yang tidak mampu mengadu tahap kesakitan.

Permarkahan
Kategori
0 1 2
Kadang terlihat
Tiada ekspresi
muka berkerut, Rahang terkancing,
tertentu di wajah
murung, tidak dagu berketar (pada
Wajah atau dalam
bermaya atau tidak kadar kerap hingga
keadaan tersenyum
bersemangat berterusan)

Menendang –
Keadaan tidak
Kedudukan biasa nendang atau
nyaman, resah atau
Kaki atau selesa membengkokkan
tegang
kaki

Berbaring tenang,
Berguling,
berkedudukan
berganjak depan Meringkuk, kaku
Aktiviti biasa, bergerak
dan belakang, atau menggelupur
dengan nyaman
tegang
Menangis
Tidak menangis
berterusan, berteriak
(keadaan tidur atau Merengek dan
Tangis dan teresak-esak,
terjaga) kadang mengeluh
sering mengeluh

Masih dapat
dipujuk dengan
sesekali sentuhan,
Tenang
Kebolehpujukan pelukan atau kata- Sukar dipujuk
kata sehingga
mudah terganggu

Setiap kategori diberi markah 0-2 dengan jumlah keseluruhan 0-10

19
Appendix 1.2 IASP Faces Scale

Explain to the child that each face is for a person who feels happy because he has no pain
(hurt) or sad because he has some or a lot of pain.

- Face 0 is very happy because he doesn’t hurt at all.

- Face 2 hurts just a little.
- Face 4 hurts a little more.
- Face 6 hurts even more.
- Face 8 hurts a whole lot.
- Face 10 hurts as much as you can imagine, although you don’t have to be crying to
feel this bad.

Ask the child to choose the face that best describes how he is feeling.

20
Appendix 1.3 Example of Pain Assessment Chart

21
Appendix 1.4 FLOW CHART FOR PAIN MANAGEMENT IN ADULT PATIENTS IN
HOSPITALS (PARAMEDICS)

22
Appendix 1.5 FLOW CHART FOR PAIN MANAGEMENT IN ADULT PATIENTS IN
PRIMARY CARE (PARAMEDIC)

Greet patient

Explain to patient Pain

Assessment Tool

Assess pain
Pain score ≥ 4 Pain score < 4
score

Inform Doctor

Serve medication

Reassess after
½ hour

Refer doctor
for
Pain score ≥ 4 investigation
of underlying
cause

23
Management of Pain in Adult Patients
Guidelines for DOCTORS

24
2.1 INTRODUCTION:

Pain is under-treated for various reasons and inadequate pain assessment has been
identified as one of the greatest barriers to effective pain management. There is also
a general lack of awareness of the importance of pain assessment.

Pain as the 5th Vital Sign was launched by the Ministry of Health (MOH) in 2008 as
one of the strategies to enhance the pain services in the country. This is also one of
the essential elements of achieving a status of “Pain Free Hospital”, a concept
proposed by the MOH in 2011. The Pain as the 5th Vital Sign is now further extended
to primary healthcare since 2015 and Oral Health in 2018. It is now known as Pain
Free Programme.

Implementation of Pain as the 5th Vital Sign allows better assessment of pain leading
to better and effective pain management in both primary care and hospital settings.
This will result in reducing unnecessary referrals and hospitalization, early
ambulation, faster recovery and reduced length of hospital stay.

2.2 DEFINITION OF PAIN

Pain is "an unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage”.

Merskey and Bogduk, International Association for the Study of Pain (IASP) 1994.

2.3 CLASSIFICATION OF PAIN

Basis of classification Types of pain

Duration Acute Pain (less than 3 months)
Chronic Pain (more than 3 months)
Acute on chronic pain
Cause Cancer Pain
Non-cancer pain
Mechanism Nociceptive pain (physiological)
Neuropathic pain (pathological)
Table 2.3.1: Types of Pain

25
Acute Pain Chronic Pain
Onset and timing Sudden onset, short duration. Onset may be insidious. Pain
Resolves or disappears when persists despite tissue healing
tissues heal.

Duration Less than 3 months More than 3 months

Signal A warning sign of actual or Not a warning signal of

potential tissue damage damage: a false alarm

Severity Severity correlates with Severity may be out of

amount of damage proportion of damage. There
are ‘Good days” and ‘Bad days”

CNS involvement CNS intact CNS may be dysfunctional

Acute pain is a symptom Chronic pain is a disease

Psychological Less, but unrelieved pain can Often associated with

effects cause anxiety & sleeplessness depression, anger, fear, social
(which improves when pain is withdrawal, etc.
relieved)

Common causes • Surgery • Headache

/ Examples • Fracture • Low back pain
• Burns or cuts • Cancer pain
• Labour and childbirth • Arthritis pain
• Myocardial infarction • Chronic pancreatitis
• Inflammation e.g. abscess, • Chronic abdominal pain
appendicitis from “adhesion colic”
• Neuropathic pain

- e.g.Post-herpetic neuralgia
- Diabetic peripheral
neuropathy
- Post-spinal cord injury pain
- Central post-stroke pain

Table 2.3.2: Differences between acute and chronic pain

26
Nociceptive pain Neuropathic pain
“Physiological pain” “Pathological pain”

Cause Obvious tissue injury Nerve injury or

Central/peripheral nervous
system abnormality

Function Protective function No discernable biological

function

Description of pain Sharp Burning

Dull Shooting
Throbbing Stabbing, lancinating
Well localised Poorly localised

Aggravating / relieving Aggravated by movement Spontaneous pain

factors Relieved by rest

Other symptoms None or related to underlying Numbness

pathology Pins and needles
Allodynia
Dysaesthesias
Table 2.3.3: Differences between Nociceptive pain and Neuropathic pain

Nociceptive Pain

Nociceptive pain is pain resulting from activity in neural pathways cause by actual tissue
damage or potentially tissue damaging stimuli. E.g. mechanical low back pain, post-
surgical pain or sports injury.

Neuropathic Pain

Neuropathic pain is defined as pain that is caused by a lesion or disease of the

somatosensory system (IASP 2011). It could be peripheral neuropathic pain due to
damaged nerve (trauma or diabetic peripheral neuropathy) or central neuropathic pain
due to injury to spinal cord or brain (neuropathic pain in spinal cord injury or central post
stroke pain) and maintain by a number of different mechanisms. This is a pathological
pain.

27
2.4 ADVERSE EFFECTS OF UNRELIEVED SEVERE ACUTE PAIN

1) Physiological
a) Cardiovascular system: increased HR, BP, increased risk of myocardial
ischaemia
b) Respiratory system: atelectasis, increased risk of hypoxemia, orthostatic
pneumonia
c) Neuro-endocrine: increased stress hormones
d) Musculoskeletal: immobility, deep vein thrombosis
e) Gastrointestinal system: ileus
f) Higher risk of developing chronic pain e.g. post-surgical pain syndrome

2) Psychological
a) Anxiety
b) Insomnia

3) Economic
a) Increased in-hospital complications
b) Prolonged length of stay in the hospital
c) More frequent visit to health clinics
d) Increased health care utilization and costs
e) Reduce productivity

2.5 PAIN PHYSIOLOGY

Pain physiology is essential as it allows us to have a better understanding of pain and

approach to treatment of pain. Nociception is the neural process of encoding
noxious stimuli; transduction refers to the conversion of noxious stimuli to action
potential, which is then transmitted along the pain pathway to the sensory cortex in
the brain where perception of pain occurs.

28
Figure 2.5.1: Pain Pathway

Tissue injury leads to release of chemicals stimulating the pain receptors (nociceptors)
resulting in generation of pain signal that is transmitted along the Aδ or C nerve to spinal
cord. These nerves synapse in the dorsal horn of the spinal cord (1 st relay station) with
the second order neurons, which cross over to the opposite side and ascend as the
spinothalamic tract. Another synapse occurs in the thalamus (2ndrelay station) from
where information is carried to the sensory cortex (where pain is perceived), the limbic
system (emotional aspect of pain) and the brainstem.

The pain pathway is not a rigid pathway but is subjected to modulation along its pathway
at the spinal cord or brain. These can be ascending or descending, inhibitory or
facilitatory modulation that will decrease or enhance pain perception. For example:
anxiety enhances but relaxation decreases pain perception.

Importantly, nociception is not the same as perception of pain. Pain perception is

affected by many factors including emotions and psychological factors, cultural belief
and coping strategies.

29
2.6 PAIN ASSESSMENT

Pain assessment requires taking a detailed pain history. We use the PAIN approach
in this guideline.

P Place Where is your pain?

A Aggravating factors What makes your pain worse?
What is your pain score now? At rest and on
movement.
I Intensity What is the worst level of pain (score) you
experience in a day?
What is the least pain (score) you experience in a
day?
Describe your pain – e.g. aching, throbbing,
Nature burning, shooting, stabbing, sharp, dull deep,
N
Neutralizing factors pressure, etc.
What makes your pain better?
Table 2.6.1: PAIN Approach

Other questions to ask about pain (more important in patients with chronic pain)
• Pattern of pain:
o Is the pain always there (constant)? Or does the pain come and go
(intermittent or episodic pain)?
• Associated symptoms:
o Do you have the following symptoms in the painful area or elsewhere?
o Numbness, tingling, allodynia (pain from a non-painful stimulus),
hyperalgesia (pain out of proportion to a painful stimulus)
• Impact of pain on mood and function:
o How does the pain affect your sleep? Your appetite? Your mood? Your
daily activities? Your relationships? Your work?
• Past History:
o Past medical/surgical history, past and current medications.
• Other information:
o Patient’s understanding about his/her pain and its cause; expectations
about pain management.

30
Pain assessment tools

Self-report of pain is the gold standard. The clinical tool that is widely available in our
hospitals is the Ministry of Health (MOH) pain scale shown below. This is used in adult
and in children more than 7 years old.

Figure 2.6.1: MOH Pain Scale.

In children less than 7 years and cognitively impaired adults, other scales like FLACC scale
(refer Appendix 1.1a & 1.1b) and IASP Faces Scale (refer Appendix 1.2) can be used. In
patients who are sedated and intubated, pain assessment will rely on observation and
behavioral assessment.

When should pain be assessed?

Pain should be assessed together with the other 4 vital signs (heart rate, blood pressure,
respiratory rate and temperature):
• Regularly at 4-hour intervals or upon any special orders,
• On admission
• Transfer in
• Whenever the patient complains of pain
• During and after any painful procedure (e.g. wound dressing)
• Reassessment of pain after interventions (e.g. administration of pain medications
or other non-pharmacological interventions)
• Upon discharge

Pain should be assessed not just at rest but also on movement and with functions e.g.
deep breathing, coughing.

31
2.7 MANAGEMENT OF ACUTE PAIN

Acute pain management is classified into:

1. Non-pharmacological
2. Pharmacological

Rest, Immobilisations, Cold compression, Elevation (RICE)

Physiotherapy TENS
approaches Heat/Cold pack
Stretching exercise
Strengthening exercise
Explanation and reassurance
Psychological Address anxiety
approaches Breathing relaxation
Counseling

Traditional / Acupuncture
complementary Massage/ Aromatherapy
medicine Music
Occupational Modification of activities of daily living, play, leisure and work
Therapy
Table 2.7.1: Non-pharmacological approaches

Pharmacological approach

• Analgesic medications can be broadly classified into non-opioids and opioids.

• Non-opioids include Paracetamol, NSAIDs, COX-2 inhibitors.

• Opioids can be further classified into weak opioids (Tramadol, Codeine,

Dihydrocodeine) and strong opioids (Morphine, Oxycodone, Pethidine,
Fentanyl).

• Other adjuvant medications, used mainly in the management of neuropathic

pain, include antidepressants (amitriptyline, duloxetine) and anticonvulsants
(carbamazepine, gabapentin and pregabalin).

Refer Appendix 2.1 for more information on analgesic medications.

32
Placebo

A placebo treatment involves giving a patient a medicine that has no pharmacological

effect (e.g. giving an injection of saline for pain). Because psychological factors are very
important, the patient’s pain may improve. If the placebo treatment works, this does not
mean the patient did not have pain in the first place or that the patient was lying!

Analgesic Strategies

Regular assessment of pain will be carried out by nurses. They will alert doctors when
patient’s pain score is ≥ 4 (refer Appendix 1.4). Management by doctors is outlined in the
flowchart in Appendix 2.2. Primary care pain management can be referred to Appendix
2.3.

Analgesic ladder for acute pain

The WHO analgesic ladder recommends using simple analgesics (paracetamol, NSAIDs)
for mild to moderate pain. For moderate pain, additional weak opioids (tramadol,
dihydrocodeine or DF-118) should be considered. In patients with moderate to severe
pain, strong opioids like morphine must be offered. In addition, adjuvants are used for
neuropathic pain at all steps of the analgesic ladder.

A modified analgesic ladder for management of acute pain is shown in Appendix 2.4.

Intravenous morphine pain protocol

Rapid control of severe acute pain may be necessary in certain situations e.g.
• In the recovery ward, immediately after an operation
• In the emergency department, following acute trauma
• To manage episodes of incidental pain e.g. wound dressing, physiotherapy
• In severe acute exacerbation of pain in cancer patients

Rapid pain relief can be achieved by titration, i.e. by giving repeated small intravenous
bolus doses of opioid (e.g. morphine 0.5 or 1mg every 5 minutes) until the patient is
comfortable.

The smaller and more frequent intravenous doses permit a more rapid, predictable and
readily observable response and allow titration of dose to response. Indeed, this is the
rationale behind PCA and explains the success of this technique.

The practical application of this is shown in the “IV Morphine Pain Protocol”. (Refer
Appendix 2.5)

33
2.8 THE R-A-T APPROACH TO PAIN MANAGEMENT
*(adapted from Morriss & Goucke 2011, Essential Pain Management Workshop Manual, pp 27-30).

The R-A-T approach provides a simple framework for pain management by any
healthcare provider, and is outlined below.

R = Recognize
A = Assess
T = Treat

RECOGNISE
We sometimes forget to ask whether the patient has pain and sometimes patients
don't or can't tell us. If you don't look or ask, you don't find!

1. Does the patient have pain?

a. Ask
b. Look (frowning, moving easily or not, sweating?)

2. Do other people know the patient has pain?

a. Other healthcare workers
b. Patient's family

ASSESS
To treat pain better, we need to think about the cause and type of pain. We may be
able to better treat the injury that is causing the pain. We may also be able to choose
appropriate drugs to treat the pain itself.

1. Measure the severity

a. What is the pain score? (Use the MOH Pain Scale, Faces Scale or FLACC Scale)
i. At rest
ii. With movement

b. How is the pain affecting the patient?

i. Can the patient move, cough?
ii. Can the patient work?

2. Make a pain diagnosis

a. Acute or chronic?
The cause of acute nociceptive pain may be obvious, but chronic pain may be
more complicated. In chronic pain, psychological factors may be more
important and the pain may have both nociceptive and neuropathic features.
The pain may also be acute on chronic (e.g. fracture in a patient with chronic
cancer pain).

b. Cancer or non-cancer?
Does the patient's disease explain the pain?
34
There may be an obvious cause of the pain that requires specific treatment.
E.g.
i. Fracture needing splinting or surgery
ii. Infection needing cleaning and antibiotics

c. Nociceptive or neuropathic?
Neuropathic pain is more likely in some situations, e.g. Diabetes Mellitus,
nerve injury (including amputation), chronic pain and cancer pain.

To diagnose neuropathic pain, ask about specific symptoms, e.g. burning,

shooting, pins and needles, numbness. Allodynia and phantom limb pain are
also neuropathic pain.

3. Are there other factors?

a. Physical factors (other illnesses)
b. Psychological and social factors
i. Anger, anxiety, depression
ii. Lack of social support

Pain diagnosis examples:

a. Acute non-cancer nociceptive pain
b. Chronic cancer neuropathic pain

TREAT
Treatment can be divided into non-pharmacological and pharmacological treatments.
Both types of treatments are important. Many factors may be contributing to an
individual patient’s pain, so there is no set list of treatments. The exact treatment will
depend on the individual patient, the type of injury or disease, the type of pain and
other factors contributing to the pain.

1. Non-pharmacological treatments
a. Physical
i. RICE (Rest, immobilization, cold compression, elevation)
ii. Nursing Care
iii. Physiotherapy, Occupational therapy, acupuncture, massage
iv. Surgery and/ or nerve blocks may be required

b. Psychological
i. Explanation and reassurance
ii. Input from social workers or religious leader
iii. Family support

35
2. Pharmacological treatments
a. Nociceptive Pain - use the Analgesic ladder (Appendix 2.4)
i. Mild - Paracetamol (± NSAIDs)
ii. Moderate - Paracetamol (± NSAIDs) + weak opioid (Tramadol or
DF118).
iii. Severe - Paracetamol (± NSAIDs) + strong opioid (Morphine)
b. Neuropathic Pain -
i. Traditional analgesic medications may not be useful
ii. Use other drugs (antineuropathic agents or adjuvants) -
Amitriptyline, Carbamazepine, Gabapentin
iii. Do not forget non-pharmacological treatments

2.9 MANAGEMENT OF SIDE EFFECTS

Side effect of opioids administration:

• nausea and vomiting – common
• respiratory depression – uncommon but life-threatening

Nausea and vomiting

Treatment options:
• Metoclopramide 10-20 mg stat and 6-hourly
• Ondansetron 8 mg IV stat and 8H if necessary
• Granisetron 2 mg IV stat and 8H if necessary
• Haloperidol 1 mg BD IV or 1.5 mg BD oral
• Dexamethasone 4 mg IV stat

Pain treatment should be continued.

Respiratory depression

Varying degree of respiratory depression can occur with the use of opioids. It is an
uncommon side effects following appropriate dosage of opioids. Occurrence of
respiratory depression is always associated with sedation. Risk of respiratory
depression is minimal if strong opioids are titrated to its effect and are used
appropriately for pain relief. (i.e. not to help patients to sleep or to calm down agitated
patients). It is also rare in patients who are on chronic opioids use (e.g. patients on
morphine for cancer pain). Presence of pin-point pupils usually confirms opioid-induced
respiratory depression.

36
Respiratory depression warrants intervention when
• The respiratory rate is <8/minute AND sedation score* = 2 (difficult to arouse)
or
• Sedation score is 3 (unarousable)

* Refer Appendix 2.6 for sedation score

Management:
1. Stop all opioids and sedative medications.
2. Administer oxygen via (face mask or nasal prongs)
3. Stimulate the patient and tell him/her to breathe
4. Dilute Naloxone 0.4mg/ml in 4 mls of water or normal saline. Administer
Naloxone in aliquots of 0.1 mg up to 0.4 mg every 1-2 minutes till patient wakes
up or respiratory rate >10/minutes.
5. Monitor respiratory rate, sedation score hourly for next 4 hours.
6. Repeat another dose of naloxone if respiratory depression recurs.
7. Refer the patient to the ICU / HDU for close monitoring +/- naloxone infusion in
severe or recurrent respiratory depression.

Summary

Pain can be acute or chronic, cancer or non-cancer, nociceptive or neuropathic. It is

important to differentiate between different types of pain, as the approach to their
treatment is different. Acute pain is a symptom of underlying disease and is usually easily
relieved while chronic pain is a disease and its management require a multidisciplinary
multimodal approach.

37
2.10 REFERENCES

1. Pekeliling Ketua Pengarah Kesihatan Bilangan 9 Tahun 2008. : Pelaksannaan

Tahap Kesakitan Sebagai Tanda Vital Kelima ( Pain as Fifth Vital Sign) di
Hospital-hospital Kementerian Kesihatan. Bahagian Perkembangan Perubatan,
Kementerian Kesihatan Malaysia, 2008.
2. IASP Taxonomy Working Group (2011) Changes in the 2011 List URL:
http://www.iasp-
pain.org/Content/NavigationMenu/GeneralResourceLinks/PainDefinitions/defa
ult.htm (accessed 16 Aug 2013).
3. Macintyre PE & Schug SA. Acute Pain Management: A Practical Guide. Saunders
Elsevier London; 2007.
4. Macintyre PE, Scott DA, Schug SA et al. Acute Pain Management: Scientific
Evidence. 3rd edition. 2010. Australian and New Zealand College of Anesthetists
and Faculty of Pain Medicine.
5. Merskey H & Bogduk N. Classification of Chronic Pain. 2 ed. Seattle:
International Association for the Study of Pain; 1994.
6. Ministry of Health Malaysia. Clinical Practice Guideline for Management of
Cancer Pain. Malaysia: MOH; 2010.
7. Morriss W & Goucke R (2011) Effective Pain Management. Retrieved from
http://www.fpm.anzca.edu.au/fellows/essential-pain-
management/EPM%20Manual%202012-04-19%20-compressed.pdf (accessed 1
Sept 2013).
8. Wong D, Baker C 1988. Pain in children: comparison of assessment scales.
Pediatric Nursing 14:9-17.
9. World Health Organization. Cancer pain relief. (Second edition) with a guide to
opioid availability. Geneva: WHO; 1996

38
Appendix 2.1 Notes on Analgesic Medications

1. List of analgesic medications:

NON OPIOIDS
• Paracetamol
• NSAIDs
• Diclofenac (Voltaren)
• Mefenamic Acid (Ponstan)
• Ibuprofen (Brufen)
• Naproxen (Naprosyn, Synflex)
• Ketoprofen (Orudis, Oruvail)
• Meloxicam (Mobic)
• COX2 inhibitors
• Celecoxib (Celebrex)
• Etoricoxib (Arcoxia)
• Parecoxib (Dynastat)
OPIOIDS
• Weak opioids
• Dihydrocodeine (DF118)
• Tramadol (atypical opioid; also increases the levels of serotonin
and noradrenaline in the CNS)
• Strong opioids
• Morphine
• Fentanyl
• Oxycodone
• Pethidine
• Partial agonist opioids
• Nalbuphine

ANTINEUROPATHIC AGENTS
• Antidepressants
o Tricyclic antidepressants
▪ Amitriptyline
▪ Nortriptyline
• Anticonvulsants
o Carbamazepine
o Gabapentin
o Pregabalin
• Others
o Ketamine

39
2. Pharmacology of NSAIDs and COX2 inhibitors
a. 4 major effects
• Analgesic
• Anti-inflammatory
• Anti-pyretic
• Anti-platelet

b. 5 major side effects:

• Allergic reaction (cross allergy is common between different NSAIDs
/ COX2 inhibitors)
• Gastric irritation / ulceration / bleeding (less with COX2 inhibitors)
• Reduced renal blood flow (long term use can lead to renal failure)
• Anti-platelet effect (can lead to bleeding; less with COX2 inhibitors)
• Cardiovascular effects – (increased risk of stroke and myocardial
infarction, more in COX2 inhibitors)

Note: the main difference between NSAIDs and COX2 inhibitors is that COX2
inhibitors have a lower incidence of peptic ulceration and upper GI bleed, and
COX2 inhibitors have less risk of bleeding.

3. Pharmacology of Morphine
Introduction:
• Acts on the mu and kappa opioid receptors in spinal cord and brain
• Potent analgesic agent – the “gold standard” opioid analgesic
• Commonly used as an analgesic in moderate to severe acute pain
• Also used in moderate to severe cancer pain, and sometimes in chronic
non-cancer pain.

Pharmacokinetics:
• Bioavailability of oral route is 30% due to first pass effect (metabolized in
liver)
• Converted to morphine-6-glucuronide (active metabolite) and Morphine-3-
glucuronide in liver
• Elimination half-life is 3-4 hours, excreted via kidney
• Caution in patients with impaired liver and/or renal functions
• Peak analgesic effect:
▪ IM / SC: 30 minutes
▪ IV: 5 minutes

40
4. A note on Pethidine in acute pain management
Pethidine is a popular analgesic in Malaysian hospitals, both in the wards as well as in
the emergency department. However, pethidine is NOT recommended in
postoperative pain relief and in chronic or recurrent pain conditions because of the
active metabolite, norpethidine, which can accumulate in the body with prolonged
use of high doses, and in renal impairment and give rise to convulsions. In addition,
Pethidine is thought to have a higher addiction potential when compared to other
opioids.

5. Naloxone
Naloxone is a pure opioid antagonist.
Doses for treating opioid-induced respiratory depression:
• Adult: 0.1 – 0.4 mg IV/IM/SC; IV dose may be repeated every 1-2 minutes
• Paediatric: 0.01 mg/kg IV (maximum 0.4 mg), repeat every 2 minutes.

The half-life of naloxone is 45-60 minutes; this is important to know because when
used to antagonize respiratory depression due to morphine, the effect of naloxone
may wear out before the effect of morphine (half-life 3-4 hours). Therefore, after
treating morphine-induced respiratory depression, the patient has to be monitored
closely for at least another 4 hours, to monitor potential risk of re-depression .
It is available in ampoules of 0.4 mg/ml (adult dose) or 0.02 mg/ml (paediatric dose).
Naloxone should be available in every emergency drug trolley.

41
Appendix 2.2 FLOW CHART FOR PAIN MANAGEMENT IN ADULT PATIENT IN
HOSPITALS (DOCTORS)

42
Appendix 2.3 FLOW CHART FOR PAIN MANAGEMENT IN ADULT PATIENT
IN PRIMARY CARE (DOCTORS)

Greet patient

Pain assessment

Acute Pain Chronic pain

(pain > 3 months)

Assess pain score • To rule out new acute

condition
• Multidisciplinary approach:
▪ Pharmacotherapy
Pain score < 4 Pain score ≥ 4 ▪ Active physiotherapy
▪ Psychological therapy
• Set up long term plan and
regular follow-up
• Emphasis self-management
Reassurance

ORDER analgesic REVIEW analgesics

if had been ordered
(Refer Appendix 2.4 )
( Refer Appendix 2.4 )

(R

Assess underlying Inform paramedic to serve medication

cause and treat
accordingly Pain score ≥ 4-6

Reassess after 30
min- 1 hour

Pain Score > 6

Refer FMS/
Hospital

FLOW CHART FOR PAIN MANAGEMENT IN ADULT PATIENTS IN PRIMARY CARE ( DOCTORS)
43
Appendix 2.4 Analgesic Ladder for Acute Pain Management

Figure 2.1. Analgesic ladder for acute pain management

Notes:
1. Dihydrocodeine (DF118) may be used as an alternative to Tramadol
2. In NBM patients oral drugs may be replaced by
a. Tramadol SC or IV
b. PCM rectal
c. Diclofenac rectal or Parecoxib IV
3. NSAIDs should be used with caution in pregnant patients and patients with
asthma, thrombocytopenia, coagulopathies, and renal, hepatic or cardiac
impairment.
4. NSAIDs are contraindicated in patients with hypovolemia, active peptic
ulceration and those with a history of hypersensitivity, e.g. wheezing to aspirin
or any other NSAIDs/COX2 inhibitors.
5. In the elderly (over 65 years) consider using a lower dose of NSAIDs/COX2
inhibitor.
6. Those at risk of gastrointestinal problems or with symptoms (epigastric pain)
may be “buffered” with Proton Pump Inhibitors.
7. For those with severe pain, use SC or IV morphine and titrate to comfort (see
Appendix 2.4 Morphine Pain Protocol)
8. Oxycodone (IV/oral) should only be used by APS team

44
Appendix 2.5 IV Morphine Pain Protocol

45
Appendix 2.6 Sedation score

Score Sedation level Clinical findings

0 None Patient is awake and alert

Occasionally drowsy, easy to rouse, and can stay awake once
1 Mild
awoken
Constantly drowsy, still easy to rouse, unable to stay awake
2 Moderate
once awoken

3 Severe Somnolent, difficult to rouse, severe respiratory depression

S Sleep Patient asleep

46
Appendix 2.7 Principles of management of chronic non-cancer pain

• Firstly, one needs to differentiate between acute and chronic pain. If the pain
has been present for more than 3 months, then this patient has chronic pain
(refer Table 2.1, Differences between acute and chronic pain).

• Often, the patient is already “known” to have chronic pain e.g. in emergency
department where s/he is a “regular visitor” or in the surgical or orthopaedic
ward where the patient gets admitted every few weeks or months. When such a
patient is readmitted for the same complaint, one must still rule out any new
acute condition – this can be easily done if the site and nature of pain in previous
admissions had been documented. Re-investigation is required ONLY IF THE PAIN
IS IN A COMPLETELY DIFFERENT SITE OR IF THE PATIENT HAS NEW SYMPTOMS
E.G. VOMITING, LOSS OF WEIGHT.

• All patients with chronic pain who are coming for repeated admissions or
treatment because of pain should be referred to a Pain Service.

• Analgesic management of patients with chronic non-cancer pain in the ward:

o Avoid Inj. Pethidine and other injections (e.g. IM Diclofenac). Pethidine is
not recommended in chronic pain conditions because of its high addiction
potential.
o Instead, give regular oral analgesics e.g. Tramadol 50-100 mg QID +
Paracetamol 1 gram QID.
o If neuropathic pain is suspected, antineuropathic agent like amitriptyline
can be added (refer Appendix 2.1).
o Avoid the use of NSAIDs / COX2 inhibitors for longer than 1-2 weeks.
NSAIDs/COX2 inhibitors may be used for a few days to get control of a
flare up of chronic pain, but they should never be given for long term use
as the patient will have a risk of developing renal failure and have a higher
risk of cardiovascular problems (stroke and myocardial infarction).
o
• Other management of the patients with chronic non-cancer pain in the ward:
o Refer to a physiotherapist for an exercise program (tailored to the
patient’s current physical abilities) that she/he can do at home.
o Discharge the patient on a regime of regular analgesics (as described
above).
o Refer to a pain clinic for assessment and follow-up.

47
o If a pain clinic is not accessible, you may have to follow up the patient in
your clinic.
o You should emphasize to the patient that she/ he should come for
regular follow-up and not just when she/ he has flare ups (severe pain).
o When the patient comes for follow-up, focus not just on the pain itself
(it will always be there) but on function and mood, i.e. what the patient
is doing (back to work?), how she/ he is feeling and how is her/ his
relationship with his/ her family and friends.

• At a Pain Clinic, the following are carried out:

• Multidisciplinary Assessment of the patient, which includes
o Medical assessment, which includes making a diagnosis and deciding
whether any further investigations are indicated, as well as reviewing
current treatment. This is usually the task of a pain specialist.
o Physical assessment to look for primary and secondary musculoskeletal
effects of chronic pain. This is usually done by a physiotherapist.
o Psychological assessment which includes looking at the psychological
impact of the pain, level of anxiety and depression, how the patient copes
with the pain, effect on family and work, etc. This is usually done by a
clinical psychologist or psychiatrist.

• Multidisciplinary multimodal management, which includes

o Review of current treatment
o Making a plan, together with the patient, regarding initial and long-term
pain management. This usually includes more than one of the following
modalities:
▪ pharmacotherapy, using appropriate drugs
▪ nerve blocks and other interventions,
▪ active physiotherapy, including exercises and activities that
patients can do at home
▪ psychological therapy, including relaxation training and other pain
management strategies.

• In the management of chronic pain, emphasis is on self-management (what

the patient can do for him/ herself) and achieving long-term changes (e.g.
from exercise) rather than short-term gains (e.g. from short acting analgesic
medications).

48