Concepts and Challenges in Pain Management PDF

CONCEPTS AND CHALLENGES IN PAIN MANAGEMENT TIMOTHY OLADOSU OUTLINE Definitions Principles of pain Physiology of pain Classification of pain Assessment of pain Management of pain Treatment principles Non-pharmacologic treatment DEFINITIONS Pain is an unpleasant sensory an...

CONCEPTS AND CHALLENGES IN PAIN MANAGEMENT TIMOTHY OLADOSU OUTLINE Definitions Principles of pain Physiology of pain Classification of pain Assessment of pain Management of pain Treatment principles Non-pharmacologic treatment DEFINITIONS Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (IASP, 1994) Allodynia – Pain caused by a stimulus which does not normally provoke pain Analgesia – Absence of pain in response to stimulation which would normally be painful Dysaethesia – An unpleasant abnormal sensation which can be either spontaneous or provoked Hyperaesthesia - An increased sensitivity to sensation Hyperpathia – A painful syndrome characterized by an increased reaction to a stimulus, especially a repetitive stimulus, and an increased threshold Pain threshold – The least experience of pain which a subject can recognize Pain tolerance level – The greatest level of pain which a subject is prepared to tolerate Total pain – Encompasses physical, psychological, cultural, social and spiritual pain PRINCIPLES OF PAIN Pain, although unpleasant, is essential for survival as it tells us when something is wrong. Pain is an important physiologic response to stimuli that have the potential to cause damage. Understanding the physiology and classification of pain will help in the assessment and management of pain, i.e. determining the type of pain helps to determine its treatment. Stimuli that activate the nociceptors (i.e. receptors preferentially sensitive to a noxious stimulus or to a stimulus which would become noxious if prolonged) is perceived as pain. Pain is influenced by many different factors and therefore total pain encompasses physical, psychological, cultural, social and spiritual factors. Psychological factors are as important in dealing with pain as the physical cause of the pain. Pain can be caused by a disease (e.g. cancer), its consequences (e.g. opportunistic infections), treatment (e.g. chemotherapy) or concurrent disorders (e.g. arthritis). PHYSIOLOGY OF PAIN Pain pathways involve the peripheral nervous system and central nervous system. The sensation of pain is made up of an initial fast, sharp pain and a later slow, dull, long-lasting pain and this is due to the difference in the speed of the nerve impulses in the different nerve-fibre types. When cellular damage occurs, a number of chemical substances are produced or released which influence the degree of nerve activity and therefore the intensity of the pain sensation. Pain from internal organs is perceived at a location that is not the source of the pain i.e. referred pain. Chronic pain can result in an altered perception to pain, leading to increased sensitivity or abnormal sensations such as burning or numbness. CLASSIFICATION OF PAIN Pain can be classified according to: Duration – Acute, Chronic Underlying mechanism – Nociceptive, Neuropathic Situation – Breakthrough, Incident, Procedural CLASSIFICATION ACCORDING TO DURATION ACUTE PAIN: Is usually due to a definable acute injury or illness Has a definite onset and its duration is limited and predictable Is accompanied by anxiety and clinical signs of sympathetic over-activity It is almost invariably the first step in the development of chronic pain Treatment is directed at the acute illness or injury causing pain, with the short-term use of analgesics  CHRONIC PAIN: Results from a chronic pathological process; Has a gradual or ill-defined onset, continues unabated and may become progressively more severe; persists longer than the expected healing time for the injury or illness in question; Often leads to the patient appearing depressed or withdrawn and possibly being labelled as ‘not looking like somebody in pain’; Offers no protective benefits, serves no purpose and has detrimental effects causing changes at the level of the nervous system as well as psychological burden Treatment is directed at the underlying disease where possible, along with regular use of analgesics to relieve pain and prevent recurrence as well as psychological supportive care QUIZ Why is acute pain said to be protective in nature? It warns an individual of tissue damage or disease It enables the person to increase personal strength As a subjective experience, it serves no purpose As an objective experience, it aids diagnosis CLASSIFICATION ACCORDING TO UNDERLYING MECHANISM NOCICEPTIVE: Nociceptive pain is produced by stimulation of specific sensory receptors in the viscera and somatic structures (although the nerves are intact). Characteristics: Somatic pain: superficial (cutaneous) in skin, subcutaneous tissue or mucous membranes: sharp and well localized pain, deep muscles, tendons, joints: more diffuse and dull; Visceral pain from organs: dull and poorly localized - the sensation of pain may be referred to a cutaneous site, often associated with autonomic responses (e.g. sweating, nausea)  NEUROPATHIC: Produced by damage to the central or peripheral nervous system (the nerves are abnormal) Characteristics: Burning pain (dysaesthesia) Shooting pain (lancinating) Aching sensation relieved by pressure applied to the affected area Increased sensitivity to a pain stimulus (hyperalgesia) or to a stimulus that is not normally painful (allodynia) Neuropathic pain is a clinical description (not a diagnosis), which requires a demonstrable lesion, or a disease that satisfies established neurological diagnostic criteria CLASSIFICATION ACCORDING TO SITUATION Breakthrough pain – a transitory exacerbation of pain that occurs on a background of otherwise controlled pain. Incident pain – occurs only in certain circumstances (e.g. after a particular movement). Procedural pain – related to procedures or interventions ASSESSMENT OF PAIN The PQRST pneumonic offers valuable guidelines for questions to help assess and measure pain: Precipitating and relieving factors: What makes your pain better/worse? Quality of pain (e.g. burning, stabbing, throbbing, aching, stinging): How would you describe your pain? What does it feel like? Ask (where possible) the patient to describe their pain for you. The choice of words in this description is important – for example, words such as ‘shooting’, ‘burning’, ‘dull’ or ‘aching’ could refer to neuropathic pain, which will require a specific type of drug intervention. Radiation of pain: Is the pain in one place or does it move around your body? Site and severity of pain: Where is your pain? (use a body chart) How bad is it? (use a Visual Analogue Scale). Timing and previous treatment for pain: How often do you get the pain? Are you pain free at night or on movement? Are you on any pain treatment or have you been in the past? Does it help? NUMERIC PAIN RATING SCALE Pain levels from 0-10 can be explained verbally to the patient using a scale in which 0 is no pain and 10 is the worst possible pain imaginable Patients are asked to rate their pain from 0 to 10 Record the pain level to make treatment decisions, follow-up, and compare between QUIZ The nurse is assessing a patient’s pain. The patient is tearful, hesitant to move, and grimacing. When asked, the patient rates the pain as a two (2) at this time using a zero (0) to ten (10) pain scale. What conclusion would be most accurate? The patient has rated the pain as minimal according to the scale The nurse should reinforce teaching about the pain scale number system The nurse should reassess the pain in 30 minutes The medication the patient is receiving is not adequate for pain relief WONG-BAKER FACES SCALE Use in children who can talk (usually 3 years and older) Explain to the child that each face is for a person who feels happy because he has no pain, or a little sad because he has a little pain, or very sad because he has a lot of pain Ask the child to pick one face that best describes his or her current pain intensity Record the number of the pain level that the child reports to make treatment decisions, follow-up, and compare between examinations FLACC SCALE  Use in children less than 3 years of age or older children who can’t talk Use it like an APGAR (Appearance, Pulse, Grimace, Activity, Respiration) score, arriving at a score out of 10 Score each of the five categories (0-2) Add the five scores together to get the total (out of 10) The total score can be related to pain intensity QUIZ. The best way to assess a client’s pain is by ________________ Numeric pain scale Behavioral assessment Objective observation Client’s self-report MANAGEMENT OF PAIN The management of pain is based on the type and cause of the pain; the approach needs to be holistic. It is important to treat the underlying cause of the pain if it is treatable (e.g. an opportunistic infection). The aims of pain management are: Prompt relief of pain Prevention of recurrence. In the management of pain, the goals are for the patient to be pain free at night, at rest during the day, and then pain free during movement. It is important to discourage the acceptance of pain by health care workers as well as the patient and their family. Both pharmacological and non-pharmacological methods should be used to manage pain. Pain can be managed across a range of settings, including the home. It is only in severe cases where an individual may need to be hospitalized in order to get their pain under control  Each person is different and will experience pain in a different way. The concept of ‘total’ pain is important but is often neglected, with emphasis only being put on physical pain. The experience of pain is a complex one and it is important to believe the patient – just because you may not find a physical cause for the pain does not mean that the patient is not experiencing pain. Pain not reported does not mean pain not experienced – you need to ask the patient. Psychological interventions are an integral component of the management of pain  Non-opioids ibuprofen or other NSAID, paracetamol (acetaminophen), or aspirin Weak opioids codeine, tramadol, or low-dose morphine Strong opioids morphine, fentanyl, oxycodone, hydromorphone, buprenorphine Adjuvants antidepressant, anticonvulsant, antispasmodic, muscle relaxant, bisphosphonate, or corticosteroid Combining an opioid and non-opioid is effective, but do not combine drugs of the same class. Time doses based on drug half-life (“dose by the clock”); do not wait for pain to recur The WHO Analgesic Ladder Incorporates non-opioid and opioid pain relievers Extremely effective for patients with acute pain, cancer pain, and neuropathic pain (nerve pain) 80-90% of people are effectively treated TREATMENT PRINCIPLES By the mouth: Use the oral route whenever possible By the clock: Administer analgesics according to regular schedule based on duration of effectiveness rather than “as needed”, except when titrating dose By the ladder: Use the WHO analgesic ladder. If after giving the optimum dose an analgesic does not control pain, move up the ladder; do not move sideways in the same level By the patient: The right dose is the one that relieves pain. Titrate the dose upwards until pain is relieved or side effects prevent moving up further NON-PHARMACOLOGIC TREATMENT Pain is influenced by psychological, cultural, social, and spiritual factors which should also be addressed Non-pharmacological treatments do not replace pharmacological treatment, but they may be complementary Reduce symptoms Affect pain perception Assist with relaxation Improve sleep Symptoms may be reduced with use of: Surgery: Can address the source of pain Radiotherapy: Treat local pain due to tumor infiltration Other non-pharmacological treatments may reduce the perception of pain, assist in relaxation, or improve sleep Dance therapy: Uses movement to improve mental and physical well-being Music therapy: Listening to or making music may lower stress and improve mood Acupuncture: Insertion and manipulation of needles, pressure, or low- frequency electric current at specific points  Physical therapy: Movement helps to build strength, maintain energy, and contributes to overall well-being Positioning therapy: Moving bedridden patients and changing their position prevents bed sores and injury Massage therapy: Rubbing and manipulating muscles, which increases circulation and relaxation Social support: Supportive counseling and referrals to community resources and services can assist patients with finding needed emotional support Spiritual and religious support: Depending on their beliefs and faith, some patients may find support through prayer and meditation  Herbs: May be helpful or harmful Hot and cold therapy: Either one may help to decrease pain Relaxation: Most commonly used non-pharmacological technique-teach patients to intentionally relax to reduce tension and stress Deep and slow breathing: Influences autonomic and pain processing in combination with relaxation Distraction: Focus the patient’s attention away from the pain Reflexology: Use pressure points in the hand and feet that correspond to other parts of the body Aromatherapy: Use essential oils to balance, relax, and stimulate the body, mind, and soul QUIZ Chronic pain is most effectively relieved when analgesics are administered _________ On a p.r.n. (as needed) basis Conservatively Around the clock Intramuscularly