ESSENTIAL PAIN
MANAGEMENT
OBJECTIVES
To improve recognizion , assessment and
treatment of pain
To address pain management barriers
INTRODUCTION
Pain affects all of us - young and old, rich
and poor.
Pain has many causes – cancer, injury,
infection, surgery and people experience as
many different ways.
Pain is often a “hidden” problem and poorly
treated.
We do not always recognize that a person is
in pain.
WHAT IS PAIN?
For you what is pain?
P- ALAGI
A- KONG
I- INIIWAN
N- ALANG
P- ALAGI
A- KONG
I- NAAWAY
N- ILA/ NIYA
BREAK INTO SMALL
GROUPS
CASE 1
Mr 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 8
Why should we treat his pain?
CASE 2
Mrs 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?
ACCORDING TO:
THE INTERNATIONAL
ASSOCIATION FOR THE
STUDY OF PAIN
Pain is “ an upleasant sensory and emotional
experience” associated with actual or
potential tissue damage, or described in terms
of such damage”.
“Pain is what the person say’s hurts.”
WHAT ARE SOME
BARRIERS IN
TREATMENT OF
PAIN?
BARRIERS
People’s attitudes
Lack of health workers
And lack of medicines
WHY SHOULD WE
TREAT PAIN?
For patient
Treating pain is humane thing to do.
Physical: improved sleep, better appetite
Fewer medical complications.
( Heart Attack, Pneumonia)
Fewer psychological problems.
(Reduced suffering, less depression and axiety)
For society:
Reduced health costs
Patients are able to work and contribute to the
community
For the family
Able to function as part of the family
( Father and mother)
Able to provide for the family
ARE THERE ANY
REASONS FOR NOT
TREATING PAIN?
There is NO evidence that witholding pain
treatment is beneficial.
Occasionally, people make incorrect
statements about pain management.
EXAMPLE
Untreated pain makes a person stronger.
Pain treatment delays surgical diagnosis.
UNTREATED PAIN IS LIKE A RAT
Often Hidden (not recognized)
Cause lots of suffering
But... can often be treated simply and cheaply
APPROACH TO PAIN
R = Regonize
Does a patient have pain?
Do other people knows the patients pain?
A = Assess
Acute or Chronic
What type pain
Are there any factors
T = Treat
Non pharmacogical or Pharmacological
RECOGNIZE
We sometime forget to ask whether the
patient has pain and sometimes
patients don’t or can’t tell us.
DOES THE PATIENT HAVE PAIN?
By simply ASK
Look ( Frowning, moving easily or not,
sweating? )
DOES OTHER PEOPLE KNOW
THE PATIENT HAS PAIN?
Other health workers
Patient’s family
ASSESSMENT OF
SEVERITY
Pain assessment is the fifth vital signs
( along with Temp, pulse, resp.rate and
blood pressure )
Remember: It is important to assess the
severity of pain because:
It will guide us in choicing the treatment we
will use
It will helps us in measuring our response to
treatment.
SCORING SYSTEM
Verbal rating scale ( mild/ moderate/ severe
or 0 to 10 pain scale )
Visual Analogue Scale ( VAS )
Faces Pain Scale ( FPS )
Functional Activity Score ( FAS )
A. No limitation
B. Mild to moderate limitation
C. Severe Limitation
EXAMPLE OF FAS
Post laparotomy patient, ask the patient to
score his pain at rest and then during an
activity. Like Getting out of bed or by simply
ask him/her to turn side to side.
Pain score at rest :
Pain score while getting out of bed :
FAS :
CLASSIFICATION OF
PAIN
REMEMBER
Not all pain is the same:
Its important for us to classify the pain be
means of these three main questions:
I. How long has the patient had pain?
II. What is the cause?
III. What is the pain mechanism?
ACUTE VS CHRONIC
PAIN
DURATION
Acute pain: Pain for less than 3 months
Chronic pain: Pian more than 3 months or
pain persisting after an injury. Sometime
patient with chronic can experience
additional acute pain ( Acute on chronic pain
)
CANCER VS NON-
CANCER
Cause
Cancer : (e.g Pelvic pain due to uterine
cervical cancer, often cancer pain is chronic
but patient may get acute pain e.g pain due
to bone fracture from bone metastases.)
Non-cancer pain
Surgery or injury
Degenerative diseases
Childbirth
Nerve compression or injury
Pain may be acute and can may become
chronic
The cause may or may not be obvious
NORCICEPTIVE VS
NEUROPATHIC PAIN
OR MIXED
Mechanism
Norciceptive pain:
Commonest type of pain following tissue
injury
Sometime called physiological or
inflammatory pain.
Describes pain as ( Sharp, throbbing or
aching and its usualy well localised by the
patient )
EXAMPLE
Bruises
Burns
Fractures
Pain caused by overuse or joint damage, such
as arthritis or sprains.
Neurophatic Pain:
Cause by lesion or disease of the sensory
nervous system.
Sometime called pathological pain
Tissue injury may not be obvious
Describes pain as ( Burning or shooting, may
also complains of numbness or pins and
needles, pain is often not well localised.
EXAMPLE
Alcoholism
Amputation
Chemotherapy
Diabetes
Facial nerve problems
Shingles
Spine surgery
Syphilis
PAIN TREATMENT
Because many factors contribute to the amount
and type of pain, it is often necessary to use
combination of treatments to manage the pain.
NON-
PHARMACOLOGICAL
AND
PHARMACOLOGICAL
Treatments
WHAT ARE THE
NON-
PHARMACOLOGICAL
TREATMENTS?
Physical and Psychological
PHYSICAL
RICE ( Rest, ice, compression, elevation )
Surgery ( e.g drainage of abscess, removal
of inflamed appendix.)
Accupuncture, massage, physiotherapy
PSYCHOLOGICAL
Relaxation Techniques (DBE)
Explanation
Reasurrance
Counselling
PHARMACOLOGICAL
TREATMENT
PHARMACOLOGICAL TREAMENT
Medicines are often the mainstay of
treatment. Different medicines work on
different parts of the norciceptive pathways,
and it is often important to use a
combination of medicines. In addition,
combining medicines may results in fewer
side effects. Like regular paracetamol that
reduces dose side effects of morphine.
CLASSIFICATION OF PAIN
MEDICATIONS
SIMPLE ANALGESICS
Paracetamol/ Acetaminophen ( Biogeics,
Panol, Panadol )
NSAIM’s ( Aspirin, Ibuprofen, Diclofenac )
OPIOIDS
MILD Opioids
Codein
Tramadol
STRONG Opioids
Morphine Phetidine
Oxycodone
OTHER MEDICATIONS
Tricyclic antidepressants
Amitriptyline
Nortriptyline
Anticonvulsants
Carbamazipine
Gabapentin
Pregabalin
Local Anaesthetics
Lidocaine
Others
Clonidine
Ketamine
CANCER PAIN
Mild pain
Use simple analgesics.
Moderate pain
Continue simple analgesics. Add codeine or
tramadol.
Severe pain
Continue simple analgesics. Add a strong
opioid, usually morphine.
MODIFIED STEP 3
Severe pain W
STEP 1
STEP 1 Moderate pain H
Mild pain
O
Use strong
Use mild opioid opioid e.g
e.g codiene,
tramadol
morphine
Continue L
Use simple
analgesics Continue simple
analgesics.
A
simple
analgesics D
D
E
Add other medications for neuropathic pain
e.g amitriptyline, gabapentin R
NOCICEPTIVE PAIN
Severe pain
Use strong opioid plus simple analgesics.
Moderate pain
Continue simple analgesics. Change from
strong opioid to codeine or tramadol.
Severe pain
Stop opioids but continue simple analgesics.
STEP 3
REVERSE
Severe pain W
STEP 1
Moderate pain STEP 1 H
Mild pain
O
Use strong
opioid e.g Use mild opioid
morphine e.g codiene, L
Continue tramadol
simple Continue
Use simple
analgesics
A
analgesics. simple
analgesics D
D
E
R
NEUROPATHIC PAIN
Tricyclic antidepressants and anticovulsants
are likely to play an important role. Simple
analgesics may be also helpful.
Tramadol may be useful also
Occasionally strong opioids are helpful in
acute, severe, neuropathic pain, but they
may not be particular effective and their use
should be frequently reassessed.
CHRONIC NON CANCER PAIN
Pharmacological treatment in this group is
complicated because there are norciceptive
and neuropathic features.
Tricyclic anti depressants and anti
convulsants may be also helpful.
It it important to consider the potential side
effects of a long term administration of
mecications. e.g NSAIMs.
CHRONIC NON CANCER PAIN
In general, strong opioids should be
AVOIDED in chronic non cancer pain
Non pharmacological treatments are
usually very important
R- RECOGNIZE
A- ASSESS
T- TREATMENT
EXAMPLE 1
A 32 year old man caught his right hand in
machinery at work. He presents with
compound fracture of his hand.
How would you manage his pain using RAT?
RECOGNIZE
Pain easily recognized
Obvious cause, patient is most like to be
distressed.
ASSESS
Severity
Pain may be moderate to severe
Type
Acute pain, non cancer
Cause Nociceptive mechanism, pain described as
sharp, aching
Possibility of neuropathic pain is nerve injury
Other factors
Anxiety, infection if old injury
TREAT
Non pharmacological treatments
Reduce inflammation
Surgery will probably be necessary
Prevention or treatment infection
Explanation and reasurance
Pharmacological treatments
Pain will be improved by simple meications
Such as paracetamol, NSAIMs and Morphine for
severe pain
REASSESS
Repeat RAT
Record pain scores
SUMMARY
R- Ask the patient about the symptoms!
A- Moderate to severe, Acute norciceptive
non cancer
T- mixed non pharmacologic and
pharmacologic approach
EXAMPLE 2
A 51 year old man has 2 year history of
lower back pain which sometime radiates
down his right leg. He fell recently and is
now having problemws walking.
How would you manage his pain using RAT?
RECOGNIZE
Ask the patient about his symptoms!
Other people may think that the patiens is
avoiding work.
ASSESS
Severity
Pain may be moderate to severe
Use Verbal rating and FAS
Type
Chronic, non cancer
Cause there may have been a recent injury
causing acute on chronic pain.
Both norciceptive and neuropathic features.
Other factors
Multiple factors : physical, psychological and
social
TREAT
Non pharmacological treatments
Rest is often not helpful in chronic back pain
Surgery will probably be necessary (Prolapsed
disc )
Acupuncture, massage and physiotherapy may be
helpful
Explanation and reasurance
TREAT
Pharmacological treatments
Regular paracetamol and NSAIMs if acute to
chronic pain.
In general morphine is not helpful for chronic
back pain. Morphine maybe needed for acute
severe nociceptive pain.
REASSESS
Repeat RAT
Record pain scores
SUMMARY
R- Ask the patient about the symptoms!
A- Moderate to severe, Acute on chronic non
cancer pain, mixed neuropathic and
norciceptive mechanism
T- mixed non pharmacologic and
pharmacologic approach
EXAMPLE 3
A 55 – year – old woman presents with a
large breast tumour with spread to her
spine. She has severe pain.
How would you manage his pain using RAT?
RECOGNIZE
Patient may have pain in both her breast and
back.
New severe back pain my not be recognized.
Ask the patient about her pain symptoms!
ASSESS
Severity
Both breast pain and back pain may be severe.
Type
Chronic cancer pain getting worse over time,
acute musculoskeletal pain caused by spinal
mestastases
Pain may be both norciceptive and neuropathic
features. Neuropathic ( if nerve compression )
Other factors
Multiple factors : physical, psychological and
social
TREAT
Non pharmacological treatments
Nursing care, possibly surgery, treatment or
social support.
Psychological or social support
TREAT
Pharmacological treatments
Regular simple analgesics + opioid
If possible control acute, severe pain with IV
morphine
Convert to oral morphine when pain controlled
Consider amitriptyline if of neuropathic pain
(especially if poor sleep)
REASSESS
Repeat RAT
Record pain scores
SUMMARY
R- Ask the patient about the symptoms!
Patient my have pain in both her breast and back.
A- Severe, acute on chronic cancer pain and
acute musculoskeletal pain, mixed
neuropathic and norciceptive mechanism
T- mixed non pharmacologic and
pharmacologic approach
