Current Pain Management Where Are We?

By Mr. Mahmoud Abdulkareem M.S {Cairo} , FRCS {Glasgow} Consultant Surgeon, King Fahad Specialist Hospital

Pain
Pain remains one of the main reasons for medical consultation worldwide.

Why have we to treat pain?

Patients have a right to appropriate prevention, assessment and control of their pain. Pain is unpleasant, delays recovery, and adds to the trauma of illness, injury and clinical procedures. Historically, pain has been underestimated and under treated.

Pain - The fifth vital sign

Pain has been identified as the fifth vital signs by Australian and New Zealand College of Anaesthetists .(Chronic Pain Policy Coalition, 2007; ANZCA, 2005).

Pain
An unpleasant subjective experience that can be communicated to others through selfreport when possible and/or a set of painrelated behaviors.

Pain
Pain is a complex neurophysiological condition involving multiple components and their interactions, which is perceived differently among individuals. Each individual learns the meaning of the word "pain" through experiences related to injury in early life.

DEFINITION
There is no physiological, imaging, or laboratory test that can identify or measure pain. Pain is what the patient says it is. The clinician must accept the patient's report of pain (McCaffery, 1968).

Pain Pathway

Perception of Pain
Pain intensity is not proportional to the type or extent of tissue damage but may be influenced at many sites within the nervous system. The perception of pain depends on the complex interactions between nociceptive and non-nociceptive impulses in ascending pathways, in relation to the activation of descending pain-inhibitory systems

Pain Classification
Pain can be classified based on pain physiology, intensity, temporal characteristics, type of tissue affected, and syndrome: 1 - Pain physiology (nociceptive, neuropathic, inflammatory) 2 - Intensity (mild-moderate-severe; 0-10 numeric pain rating scale) 3 - Time course (acute, chronic) 4 - Type of tissue involved (skin, muscles, viscera, joints, tendons, bones) 5 - Syndromes (cancer, fibromyalgia, migraine, others) 6 - Special considerations (psychological state, age, gender, culture)

Acute and Chronic Pain

1. Acute pain - is relatively brief, and subsides as healing takes place. 2. Chronic pain - continues for a long period of time, generally is not curable, and can have episodes of exacerbation whereby certain activities or other conditions may cause the pain to reoccur. 3. Neuropathic pain - stimuli abnormally processed by the nervous system

Differences between Treatment of Acute and Chronic Pain

1. Acute Medical model of care: Reduced pain intensity is primary goal in order to facilitate recovery and prevent chronic pain Generally time limited and successful treatment ends when pain resolves 2. Chronic/Rehabilitation-disease management model of care: Improved function (physical, psychological and social) is often primary goal. Patients must actively participate in care Treatment and pain may never end

Pain Management
Pain Management means the assessment of pain and, if appropriate, treatment in order to assure the needs of residents of health care facilities who experience problems with pain are met.

Factors Contributing To Oligoanalgesia

1- A pre-occupation with the diagnosis and treatment of the underlying medical problem 2- Concerns about masking symptoms 3- Fears about contributing to or causing addiction 4- Caregiver underestimation of pain experienced by patient 5- Cultural differences in pain expression 6- Poor communication 7- Reluctance of patients to complain of pain or demand pain treatment 8- Inadequate training in the recognition and management of pain.

Why is assessment important?

Assessment of a patients experience of pain is a crucial component in providing effective pain management. A systematic process of pain assessment, measurement and re-assessment (re-evaluation), enhances the health care teams ability to achieve: a reduced experience of pain; increased comfort; improved physiological, psychological and physical function; increased satisfaction with pain management.

Goal of Pain Assessment

1. to capture the patients pain experience in a standardized way. 2. to help determine type of pain and possible etiology 3. to determine the effect and impact the pain experience has on the patientsand their ability to function. 4. basis on which to develop treatment plan to manage pain 5. to aid communication between interdisciplinary team members

ABCs of pain management:

A - Ask about pain and Assess pain systematically. B - Believe the patient's report of pain and what relieves it. C - Choose appropriate pain control for patient and setting. D - Deliver pain intervention in a timely, logical, and coordinated fashion. E - Empower the patient by enabling the patient to control their course as much as possible.

The 5 points for the correct use of analgesics are as follows:

1. Oral administration of analgesics. The oral form of medication should be privileged whenever possible. 2. Analgesics should be given at regular intervals 3. Analgesics should be prescribed according to pain intensity as evaluated by a scale of intensity of pain. 4. Dosing of pain medication should be adapted to the individual. There is no standardized dosage in the treatment of pain. Every patient will respond differently. The correct dosage is one that will allow adequate relief of pain. The posology should be adapted to achieve the best balance between the analgesic effect and the side effects. 5. Analgesics should be prescribed with a constant concern for detail.

Pain Management Techniques

1 - Noninvasive Non-Drug Pain Management

Exercise - physical exertion with the aim of increasing strength, increasing flexibility, and restoring normal motion. Behavioral modification - use of behavioral methods to optimize patient responses to back pain and painful stimuli. Cognitive therapy involves teaching the patient to alleviate back pain by means of relaxation techniques, Superficial heating or cooling of skin - These pain management methods include cold packs and hot packs, ultrasound, and diathermy and should be used in conjunction with exercise. Electrotherapy - the most commonly known form of electrotherapy istranscutaneous electrical nerve stimulation (TENS). TENS therapy attempts to reduce back pain by means of a low-voltage electric stimulation that interacts with the sensory nervous system.

Pain Management Techniques

2- Noninvasive Pharmacologic Pain Management
Analgesics - or pain medications, including acetaminophen. Long-term use may involve risk of kidney or liver damage. Nonsteroidal anti-inflammatory agents (NSAIDs) - includes aspirin, ibuprofen, naproxen and COX-2 inhibitors. Long-term use may cause gastrointestinal ulcers, and may slightly raise the risk of heart attack. Muscle relaxants - used to treat muscle spasms due to pain and protective mechanisms. Narcotic medications - most appropriate for acute or post-operative pain. Since use of narcotics entails risk of habituation or addiction if not properly supervised, they are not often used for chronic conditions. Antidepressants and anticonvulsants - used to treat neuropathic ("nerve") pain. Neuromodulating medications - used to treat neuropathic and muscular pain

The WHO Pain Ladder was developed in 1986 as a conceptual model to guide the management of cancer pain. There is now a worldwide consensus promoting its use for the medical management of all pain associated with serious illness, including pain from wounds.

Pain Management Techniques

3 - Invasive Pain Management Techniques
Invasive techniques in pain management involve injections and/or placement of devices into the body. Radiofrequency radioablation This procedure involves deadening of painful nerves via heat administered through a small needle. Surgically implanted electrotherapy devices These are implantable spinal cord stimulators (SCS) and implantable peripheral nerve stimulators.

Pain Management Guidelines

So, our goal is