Pain

unpleasant sensory and emotional experience described in terms of damage

can be
opioid responsive: visceral nocireceptive
Opioid semi responsive: somatic nocireceptive/ neuropathic
Opioid resistant: muscle cramps
1. Classification
a) Acute
associated with acute tissue injury or secondary to disease by somatic nocireceptor activation
lasts as long as the conditions persists
can be eliminated by treating underlying cause
respond with fear, anxiety and restlessness
b) Chronic
persists after acute pain causing nocireceptor stimulation=> repeated pain for months or years
the longer it persists, the more destructive it gets( physical,emotional, social)
patient describe painful symptoms, repeat attendance to doctors, personality changes
hard to diagnose and hard to treat=> needs interdisciplinary team
Neoplastic chronic pain
describes progressive tissue destruction with severe pain
seen in oil stains+ produce metastases+ pain in different locations with different characteristics

2. Characterization
a) Localisation
involves hyperalgesia and hyperesthesia, reduced strength
Local: from superficial somatic structures
Projected/ Irradiated: over a nerve
Referred: from deep somatic regions located in the innervation area of the viscera
b) Intensity
important for evaluation and analgesia administration
Low: VAS< 4
Medium: VAS4-6
High: VAS:7-10

3. Pain occurence
a) Continous pain: prolonged pain without interruption
b) Incidence pain: episodes of pain with controlled pain with sudden onset and defined cause
c) Breakthrough pain: in patients with adequate analgesic therapy without defined cause
d) Pre dose pain: in patients with insufficient daily dose of analgesia

4. Quality of pain
a) Nocireceptive
stimulates nocireceptors( somatic/visceral)
is a local pain, from superficial to profound with variable intensity
Has no neurological modification
Treat with NSAID and opioids
b) Neuropathic
Incomplete lesion
by incomplete lesion of nerves, roots or nerve plexuses
has dysesthesia, allodynia, neurological modifications
treat with antieleptics, anti depressives, opioids
Complete lesion
has burning pain, hyperalgesia, neurological modifications
 treat with antieleptics, anti depressives, local anesthetics
c) Total( Physical+ Psychological+ Social+ Spiritual)
Anxiety: of death, hospitalization, family status
Depression: loss of prestige, sense of abandonment
Exasperation: Loss of friends or family, failure of treatment

A. Pain evaluation
ability to diagnose and make an initial plan of treatment
if its caused by the disease/ treatment/ different pathology
if its nocireceptive/ neuropathic/ mixed
if it has negative effects on patient or family
if there are different kinds of pain, evaluate separately=> believe the patient
Self evaluation impossible for babies/ coma patients/ intellectual disabled
Key elements
1. Question related to pain: patient should be encouraged
2. Observe pain manifestation: by facial expression, movements, verbalization, CNS
modifications, personality changes
3. Pain description
Sensory dimension: Pain nature, localization, intensity
Affective dimension: Anxiety, depression
Pain impact: Physical/social/ Emotional/ Spiritual
4. Pain measurement
Unidimensional: measures quantity of pain using numerical or visual analogue scale (
verbal or written)
Multidimensional: measures quality of pain using Brief pain inventory(BPI) or Abbey Pain scale
> BPI: describe maximum/ minimum/ medium intensity in 24 hours, in the discussion time and
response to analgesia
> Abbey Pain scale: for person who cannot verbalize, used in dynamic assessment
5. Pain causes

B. Pain assessment
Important Factors: Physical( Symptoms)+ Psychological+ Social+ Spiritual
understanding of the diagnosis, preferences and expectations of the patient influence the
treatment
difficult to treat : neuropathic pain, psychological distress
Psychological distress
frequently encountered, manifested by anorexia, sleep disorders, altered personality
Principles
Indication investigation: Lab, x-ray=> pain must be treated, investigations needs to be
useful
Assessment of diseases extension: for prognosis( survival time) or medications
Reevaluation: after changing the treatment or if pain intensity changes
use of ESAS( Edmonton symptom assessment system): serial of 9 VAS
> ESAS: reliable assessment tool
- has 3 demands: filled out by patient+ easy to understand+ give useful information
+ : improves continuity of care, easy to apply, monitor the effectiveness of the treatment

Assessment of pain: Checklist

Checklist 1: localization, duration, Quality, continuous/ Discontinous
Checklist 2: Medications(Dose+route+duration+effects/side effects), holistic health factors

Analgesia
there is no maximum dose, only a optimum
Oral or rectal administrations is preferred=> otherwise subcutaneous
Addiction or tolerance or no problems in patients with advanced cancer
its goal is relief of pain and comfort for the patient and family
 Non-opioids: VAS < 3
Weak opioids: VAS 4-6
Strong opioids: VAS 7-10
combine 1+2 or 1+3 or coanalgesics+ 1/2/3
!!! NEVER 2+3!!!
1: Paracetamol, Diclofenac(Volatern), Ibuprofen(Nurofen), Naproxen,Indometacin
2: Codeine, Tramadol, Dihydrocodeine, Oxycodone,Pentazocine
3: Morphine, Fentanyl, Methadone, Petidine,Buprenorfine,Altenafyl
b) Side effects
Transitory: Vomiting, Sedation, Hallucination, Urinary retention
Permanent: Constipation, Xerostomia, Physical dependence, Tolerance
Accidentally: respiratory depression, myoclonus
Occasionally: Transpiration, miosis

Route of administration
look at desired effect, duration, patient wish, prevent adverse/iatrogenic effects
1) Oral
+ : good compliance, non invasive, patient independence
- : high frequency of dosing, variable plasma concentration, cant be used in digestive disorders
2) Rectal
+ : skips first-pass effect of liver metabolism
- : lower compliance, slower absorption( like oxycodon)
3) Parenteral( Intramuscular,subcutaneous, intravenous)
+ : used in patient with digestive disorders( vomiting, dysphagia), fast effect+ high potency,
controllable
- : Invasive, decreased patient independence, bolus is painful, continuous perfusion is less
invasive
Continous subcutaneous infusion
+ : digestive disorders, uncontrolled pain, coma patients, maintains constant plasma levels,
multiple drugs can be administered
- : patient refuse, thrombocytopenia/edema/irradiated areas, needs special device, volume limited
Continous intravenous infusion
+ : fast effect, multiple drugs can be administered, volume unlimited
- : needs special devices

Transdermal Fentanyl
reaches constant level after 12-24 hours, then slowly decreases
effect after 8-12 hours => first application in the morning to observe dose and prevent overdose
absorption increases at high temperature=> skin permeability increases
After removing the system, its concentration decreases to 50% after 13-22 hours
+ : constant pain, digestive disorders, good compliance, also used in renal failure
- : needs also another opioid for proper effect, don't cut fentanyl patch in smaller parts for smaller
doses !!!

Myths about opioids

1) Used when end is near: used for pain and not to severity of disease
2) causes respiratory depression: correct titration to reduce risk
3) Addiction: can cause physical dependence not psychological
4) Tolerance develops: increased dose due to progression of illness not due to tolerance only
5) has severe side effects: Nausea, vomiting disappears after few days
6) Dose in all patient is the same: needs to be individualized
7) Pain responds only to injection: also oral or patches
8) Early morphine prescription leads to depletion of analgesia: dose can be increased
9) If opioid has no effect, nothing will be efficient: needs to be individualized
10) it harms the body: can be administered for a long time
11) Reduce dose when patient is unconscious: ensure that death is painless
12) Administration only in cancer: decide by severity pain and not of disease
Only Optimum doses, not Maximum doses
Step 1: NSAID+ Paracetamol
short t 1/2:
Paracetamol: 4-6 g/ day
Diclofenac: 150-200 mg/ day
Ibuprofen: 2,4-3,2 g/ day
Indomethacin 150 mg/day
Long t 1/2( less indicated)
Naproxen: 1 g/ day
Piroxicam: 20-40 mg/day
Meloxicam: 15 mg/day
=> Side effects: digestive hemorrhage, thrombocytopenia, renal retention
Step 2:
Codeine: 240-360 mg/day: combined with aspirin or acetaminophen for stronger effect, low affinity
for receptor
Dihydrocodeine: 240-360 mg/day, slow release at 12 hours
Tramadol: 400-600 mg/ day: weak receptor agonist, longer half time than morphine
> Fast release formula: adjust daily
Codeine 30 mg every 6 hours
Tramadol 50 mg every 6 hours
easy/ moderate pain: increase by 25-50%
severe pain: increase by 50-100%
> Extended release formula: adjust 2-4 days
dont crush or chew tablets
Tramadol 100 mg every 12 hours
Step 3:
Morphine
Fentanyl
Oxycodone
Pethidine

Important
Oral morphine in naive patients
above 65 years with normal renal function : 5 mg at 4-6 hours
above 65 years with low renal function : 5 mg at 6-8 hours
under 65 years normal renal function: 10 mg at 4-6 hours
under 65 years low renal function: 10 mg at 6-8 hours
Subcutaneous morphine in naive patients
elderly with cachexia: 5 mg at 8 hours
other patients: 5 mg at 4 hours
!!! switch from oral to subcutaneous= oral dose divided by 2 for subcutaneous dose
Switch from Tramadol to Morphine= Divide tramadol by 10
Morphine titration:
>If first dose produce intense sedation, reduce by 50%
> If first dose produce no analgesia, increase by 50%
Switch from 2nd> 3rd step
> if pain was uncontrolled
> for fast release: divide dose by 6
> for extended release: divide dose by 2
Breakthrough dosage: use fast-release opioids not slow release, repeat dose after Cmax is
reached

Barriers in access to opioids

1. Traditional: other opioids, long action, other administration routes, efficient doses regularly, for
acute and chronic diseases, at hospital and home, for pain evaluation
2. Modern: pethidine, short action, injectible, small doses when needed, for acute disease, at
hospital, without evaluation