Definition of pain Types of pain Classifications of pain Clinical assessment of pain Treatment of pain

1. MANAGEMENT Of PAIN
Prepared by : Yahya Farwan.
University of Science and Technology Hospital, Sana’a, Yemen, 2023.

2. Objectives
1. To identify the meaning of pain
2. To identify the neurological pathway of pain
3. To identify the the Types/Classifications of pain
4. To identify the clinical assessment of pain
5. To identify the different methods of pain control
II

3. Table of Contents
1.1 Pain definitions............................................................................................................ 1
1.2 Pathway of pain ....................................................................................................... 2
1.3 Types / Classifications of pain ................................................................................... 3
2.1 History Taking ....................................................................................……………… 5
2.2 Clinical Examination ......................................................................................…… 8
2.3 Investigations ........................................................................................................... 9
3.1 WHO analgesic ladder ............................................................................................. 12
3.2 Oral analgesics…………............................................................................................. 16
3.3 Parenteral analgesics................................................................................................... 24
3.4 Analgesic suppositories .......................................................................................… 25
3.5 Adjuvant drugs ...............................................................................................…… 26
3.6 Management of side effects ..................................................................................... 27
3.7 Topical analgesics ......................... ........................................................................... 28
3.8 Interventional treatment .
……………………………………………………
.......... 29
3.9 Additional methods for management of pain .......................................................... 30
3.10 Management of pain in emergency department …………..………….................... 31
1. Overview
.
2 Clinical Assessment of Pain
.
3 Control of Pain
5. Resources...................................................................................... 34
III
4. Summary ...................................................................................... 33

4. List of abbreviations
• CNS Central nervous system
• PNS Peripheral nervous system
• Pt Patient
• MD Diabetes mellitus
• HTN Hypertension
• IHD Ischemic heart disease
• C.T.D Connective tissue disease
• WHO World health organization
• PRN As needed
• IV Intravenous
• IM Intramuscular
• SC Subcutaneous
• NSAIDS Non-steroidal anti-inflammatory drugs
• MI Myocardial infarction
• CABG Coronary artery bypass graft
• COX2 Cyclooxygenase 2
• SNRIs Serotonin and norepinephrine reuptake inhibitors
• PO Orally
• PR Rectally
• NRS Numerical rating scale
IV

5. Overview of the
Pain
01

6. • Pain is an unpleasant sensory and emotional experience caused by tissue damage.
• Acute pain: tissue damage that triggers a protective reaction with duration of
less than 3 months .
• Chronic pain: pain that lasts beyond the normal tissue healing time (3 months) .
• Pain is always subjective.
1.1
Definitions of
Pain
Pain is the 5th vital sign
1

7. Tissue injury
➡️Stimulation of nociceptors in superficial and deep structures
➡️ Post. Root ganglion
➡️ SGR in the posterior horn cell of the spinal cord
➡️ Cross to opposite side
➡️ Ascend in the lateral spinothalamic tract
➡️ lateral lemniscus in the brainstem
➡️ thalamus
➡️ area 1, 2, 3 in parietal lobe
➡️ ends in the cortical sensory area of opposite side. (
3
)
1.2 Pain
Pathway
2

8. 3

9. • Nociceptive pain: pain that is triggered by chemical, mechanical, or thermal stimuli (noxious stimuli)
includes:
1. Somatic pain (musculoskeletal pain): localized, sharp pain that varies in duration and quality.
2. Visceral pain: dull, diffuse, deep pain results from distension of a hollow organ (e.g intestine ) or
irritation of capsules of solid organs (e.g liver ) .
• Neuropathic pain: pain caused by abnormal neural activity that arises secondary to injury, disease or
dysfunction of the nervous system , includes:
1. Central pain: caused by CNS dysfunction (e.g., from lesions produced by an ischemic stroke)
2. Peripheral pain: caused by damage to peripheral nerves (e.g., diabetic neuropathy, postherpetic
neuralgia). (1)
Classification
s of Pain
4

10. 02
Clinical Assessment of Pain

11. History Taking
Ask about Pain
SOCRAT
5

12. • I have a chest pain
• For 2 hours
• I’m unable to engage in normal activities
• Sudden onset
• Pain not relieved by analgesics
• Location of pain helps in targeting the therapy to the right place.
• Sudden onset is more dangerous than gradual onset
• Duration to distinguishing acute from chronic pain.
• Aggravating/ Reliving factors may provide a clue to the diagnosis
• Severity of pain may provide a clue to the diagnosis
• Gradual onset
• For 5 months
• I have a lower back pain
• Pain relieved by ibuprofen
• I’m able to adapt to pain
Case 1 Case 2
History
Taking
6

13. Ask about:
• Past history: Similar condition , D.M, IHD, HTN, malignancy, C.T.D, previous
surgeries and blood transfusions…
• Family history: similar condition, Hx of chronic diseases, Hx of malignancy..
• Socioeconomic status
Severity of pain :
• Mild : Doesn’t interfere with most activities, pt able to adapt to pain psychologically and with medications.
• Moderate : Interfere with many activities, require lifestyle change but the patient is independent, pt unable to
adapt pain.
• Severe : Unable to engage in normal activities, pt is disabled and unable to function independently.
History
Taking
7

14. Physical Examination

15. 1. Assess the general condition of the patient
Hello dear, let me examine
you for :
1. Blood pressure
2. Pulse rate
3. Respiratory rate
4. Temperature
5. Pain score
The numerical rating scale
The visual analog scale
Wong–Baker faces pain scale. (1)
Physical Examination
.
2 Examine the patient locally according to the system affected
8

16. Investigation
s

17. Routine invx
CBC, blood culture, ESR and CRP, LFT, RFT, S. electrolytes
Specific invx
According to system affected.
Laboratory
Investigations
9

18. X-ray , ECHO, ECG, US, MRI , CT –As indicated
Imaging Studies
10

19. 03
Control of Pain

20. Classifications of analgesics
1. Oral analgesics
Non-opioids : Paracetamol, NSAIDs, COX2 inhibitors
Opioids : weak opioids as tramadol and potent opioids as hydromorphone
Combination analgesics : both opioids and Non-opioids
2. Parenteral analgesics
Non-opioids : as NSAIDs
Opioids : as morphine, fentanyl
3. Adjuvants drugs
Management of side effects of previously mentioned drugs.
Antidepressants
Anticonvulsants
Muscle relaxants
4 Interventional treatment of pain
Other methods of pain management
Consider
Analgesic
suppositories when
oral medication is not
tolerated.
11

21. Mild opioids
Strong opioids
Step I
Step II
Step III
3.1 WHO analgesic ladder
The WHO analgesic ladder is a 3-step algorithm for the management of acute and chronic pain.
12

22. Modified WHO analgesic ladder
Mild
Moderate
Severe
13

23. Management of pain using WHO analgesic ladder
• Nonopioid analgesics are first-line agents for pain; prescribe them alone for mild to moderate pain
and in combination with opioids for severe pain.
• For both opioid and nonopioid analgesics, use the minimal effective dose for the shortest duration
of time to minimize adverse effects.
• Pain intensity scales should be used in regular intervals to assess the success of pain management.
Pain
Severity
Nonopioid
Analgesics
Mild opioids Strong opioids
Adjuvant
Drugs
Step I Mild Include Avoid Avoid If required
Step II
Moderate
Include Consider Avoid If required
Step III Severe Include Consider Consider If required
14

24. Methods of pain control :
1. Regular analgesia (modified-release drugs, administered at fixed times and doses)
By the mouth: preferably, analgesics should be given orally.
By the clock: regular administration at fixed times, rather than on demand
By the ladder (symptom-oriented): if the patient is still in pain, it is necessary to go up a step.
2. Appropriate PRN medication
Short-acting analgesics for peaks in pain
If PRN medication is required ≥ 3×/day → inadequate analgesia likely; review the regular medication.
15

25. 3.2 Oral analgesics
1. Non-opioids:
A. Paracetamol 325–1000 mg PO every 4–6 hours PRN (max. dose 4000 mg/day).
B. NSAIDs:
• Aspirin 325–975 mg PO every 4–6 hours as needed (max. dose 4000 mg/day)
• Ibuprofen 400–800 mg PO every 6–8 hours PRN
• Naproxen sodium 250–500 mg PO every 12 hours PRN
• Diclofenac 50 mg PO every 6–8 hours or 75 mg every 12 hours PRN
C. Selective COX-2 inhibitor:
Celecoxib 400 mg PO once on the first day, then 200 mg every 12 hours PRN.
16

26. Note:
Panadol subtypes
• Paracetamol combined with other substances
• All types of panadol have the same effect on relief headaches, toothaches, joint pain,
and menstrual pain, fever, neuralgia, musculoskeletal disorders, and symptoms of
colds and flu.
• They are contraindicated if there is hypersensitivity to paracetamol or other
components of the drug
• There are some precautions lodanaP fo epyt hcae rof → READ
3.2 Oral analgesics
17

27. 18

28. Panadol Night
500mg Paracetamol +
diphenhydramine
hydrochloride 25mg (film-
coated tablets).
Indications
Effective night pain relief and
better sleep.
Dose
Two tablets, 20 minutes before
bed, with a maximum of 2
tablets/ day.
Panadol Extra
500 mg of Paracetamol and
Caffeine 65 mg (of film-coated
tablets).
Indications
Effective relief from severe
pain.
Dosage
One-Two tablets up to four
times a day with a maximum
of 8 tablets in 24 hours.
Panadol Woman
500mg Paracetamol + 10mg
hyoscine butylbromide (film-
coated tablets).
Indications
Dymenstrual and menstrual pain,
abdominal cramps.
Dosage
One-Two tablets up to three times
a day as needed with a maximum
of 6 tablets in 24 hours.
19

29. Panadol Cold and Flu All in One
250 mg Paracetamol + 100mg
Guaifenesin + 5mg Phenylephrine
hydrochloride (film-coated tablets).
Indications
Effective relief from cold + flu
symptoms and their associated body
pain, aches, and fever.It also relieves
chesty cough, fever, nasal
congestion, sore throat, headache,
and body aches.
Dosage:
One- two tablets, four times a day,
with a maximum of 8 tablets in 24
hours.
Panadol Migraine
250mg Paracetamol + 250mg
acetylsalicylic acid + 65mg
caffeine (film-coated tablets).
Indications
Effectively relieves severe
migraines from the first dose.
Dosage
Two tablets; do not take more
than two tablets in 24 hours.
Panadol Joint
665 mg Paracetamol
Indications
Fast and long-lasting relief of
osteoarthritis pain (8-hour relief
from pain).
Extended-release bi-layered
tablets for prolonged joint pain
relief
Dosage
Two to three tablets a day with a
maximum of 6 tablets/ day.
20

30. 3.2 Oral analgesics
Important notes about oral non-opioid analgesics
Paracetamol use with caution in liver failure or active hepatic disease
About NSAIDs:
• Ibuprofen and naproxen are the preferred first-line analgesics for mild to
moderate pain.
• Use with caution htiw stneitap ni
DUP
esaesid laner dna
.
• Avoid htiw stneitap ni ,elbisaef fi ,sDIASN bleeding disorders and those who will soon
undergo surgery or an invasive procedure .
• Contraindicated tnecer a htiw stneitap ni
IM
doirep evitarepoirep eht ni dna
fo
GBAC
:noitpecxe(
wol
-
esod
niripsa
etuca fo tnemeganam eht ni
)IM
According to the selective COX2 inhibitors
• Preferred second-line analgesic for mild to moderate pain.
• Preferred over NSAIDs in patients with PUD.
• Use with caution in patients with renal or cardiovascular
disease
21

31. 2. Opioids :
Tramadol 50–100 mg PO every 4–6 hours PRN
Hydromorphone hydrochloride (immediate-release) 2–4 mg PO every 4–6 hours PRN
3. Combination analgesics (opioids and non-opioids )
Consider combination analgesics for the management of moderate to severe pain.
Codeine/acetaminophen 300 mg1 to 2 tablets PO every 4 hours PRN
Hydrocodone /ibuprofen 200 mg PO every 4–6 hours PRN
Oxycodone/acetaminophen 300–325 mg PO every 6 hours PRN
3.2 Oral analgesics
22

32. • Combine opioids with nonopioid analgesics (multimodal pain control) to
minimize the dose needed for analgesia and decrease side effects.
• Monitor for respiratory depression in the first 72 hours after initiating or
increasing the opioid dose.
• Tramadol is not recommended in patients with epilepsy, as it lowers the seizure
threshold.
Opioids are contraindicated in :
Bronchial asthma Respiratory depression
Bowel obstruction Biliary colic.
Important notes about opioids
23
3.2 Oral analgesics

33. 1. NSAIDs :
Ketorolac 15–30 mg IV/IM every 6–8 hours PRN.
Ibuprofen 400–800 mg IV every 6 hours PRN.
Diclofenac 37.5 mg IV every 6 hours PRN.
2. Opioids :
Tramadol 50-100 mg IV/IM every 4–6 hours
Morphine 0.1–0.2 mg/kg IV every 4 hours as needed or 10 mg IM every 4 hours PRN
Fentanyl 0.35–0.5 mcg/kg IV every 30–60 minutes as needed (intermittent dosing)
Hydromorphone 0.2–1 mg IV every 2–3 hours PRN or 1–2 mg SQ/IM every 2–3 hours PRN.
3.3 Parenteral analgesics
24

34. 3.4 Analgesic suppositories
Consider as an alternative when oral medication is not tolerated.
Acetaminophen 325–650 mg PR every 4–6 hours PRN.
Indomethacin 50 mg PR every 8–12 hours PRN.
Aspirin 300–600 mg PR every 4 hours PRN.
25

35. 1. Antidepressants
Tricyclic antidepressants and SNRIs can be helpful for chronic pain syndromes and neuropathic pain.
Amitriptyline 10–150 mg PO once daily
Doxepin 10–150 mg PO once daily
Duloxetine 30–60 mg PO once daily
3.5 Adjuvant Drugs
2. Anticonvulsants
Useful adjuncts in the management of neuropathic pain.
Gabapentin 300 mg PO once on the first day, then every 12 hours on the second day, then every 8 hours
on the third day; titrate as needed (max. dose 1800 mg/day)
Pregabalin 75 mg PO every 6–12 hours as needed
Carbamazepine 100 mg PO every 12 hours; titrate as needed (max. 1200 mg/day).
3. Muscle relaxants
Consider muscle relaxants in patients with pain associated with muscle spasticity.
Cyclobenzaprine hydrochloride 5–10 mg PO every 8 hours as needed
Methocarbamol 1500 mg PO every 6 hours for 2–3 days; titrate as needed
Baclofen 5 mg PO every 8 hours for 3 days; titrate as needed (max. 80 mg/day)
26

36. 1. Laxatives:
Particularly with opioids.
Lactulose 15 mL PO every 24 hours PRN.
Senna tablets 8.6–17.2 mg PO every 12–24 hours PRN.
2. Antiemetic:
Particularly with opioids.
Ondansetron 4–16 mg PO/IV every 4–8 hours PRN.
Metoclopramide 10 mg IV/IM/PO every 4–8 hours PRN.
Scopolamine 0.6–1 mg SQ every 6–8 hours PRN.
3. Proton-pump inhibitors (PPIs):
With NSAIDs to prevent peptic ulcers
Omeprazole20 mg PO
Esomeprazole 40 mg PO
3.5 Adjuvant Drugs )Management of side effects(
27

37. 1. Lidocaines:
Lidocaine patch 5% : used in post-herpetic neuralgia
Lidocaine jelly 2% : used in painful urethritis
Lidocaine ointment 5% : used in minor burns, including sunburn, abrasions of the skin, and
insect bites.
2. Diclofenac:
Diclofenac 1.3% topical patch: used for acute pain due to minor strains, sprains and contusions
Diclofenac sodium 1.5% topical solution : applied to the affected area/joint every 6 hours PRN.
Diclofenac sodium 1% gel applied to the affected area/joint every 6 hours PRN, Solution and gel used
for chronic pain in osteoarthritis. (1)
3.7 Topical Analgesics
28

38. 3.8 Interventional Treatment
Nerve block:
Nonsurgical nerve blocks:
• Epidural and spinal analgesia or anesthesia.
• Peripheral nerve blockade.
Surgical nerve blocks:
.
1 Sympathetic blockade: injection of neurolytic substances, radiofrequency denervation or
cryoneurolysis of sympathetic nerves.
• Used to treat complex regional pain syndrome
□ Celiac plexus block in the treatment of intractable intra-abdominal pain, including pain in
the setting of malignant and benign neoplasms involving the pancreas, biliary tree,
retroperitoneal organs, and other abdominal organs
□ Lumbar sympathetic block for treatment of lower back or leg pain
.
2 Neurectomy: a damaged peripheral nerve is surgically removed.
.
3 Rhizotomy: removal of the root of the nerves that extend from the spine.
• used to treat different types of pain and abnormal nerve activity, such as: back and neck pain
from arthritis, herniated discs, spinal stenosis and other degenerative spine conditions
29

39. 1. Physical therapy
• Massage
• Thermotherapy
2. Behavioral therapy
• Relaxation techniques in particular help many patients to reduce stress and psychological strain, thereby
significantly alleviating pain.
• Patient education: Regarding causes and management of a patient's pain
3. Occupational and Recreational Therapy
3.9 Additional methods for pain management
30

40. Pain management in the
emergency department
Emergency Department

41. Direct the pain management to the underlying condition, E.g.,
management of pain in a myocardial infarction will differ from that of
a fractured ankle.
Take short and focused history.
Assess pain severity and analgesics used:
• Use a pain intensity scale.
• Document recent analgesic use (e.g., type and dosage of medication).
• Reassess pain severity every hour or sooner if necessary.
Provide treatment.
Pain management in the
emergency department
31

42. Mild Pain Moderate Pain Severe Pain
If pain acceptable to patient:
Reassess as necessary
If pain not acceptable:
Acetaminophen 1000mg PO/IV
If pain acceptable to patient:
Reassess as necessary
If pain not acceptable:
Diclofenac 50mg PO
or Tramadol 50mg PO
(when NSAIDs are contraindicated )
Add acetaminophen 1000m PO/IV if
not given yet 1000mg PO/IV
Fentanyl 1mcg/kg IV
(0.5 mcg/kg > 60 years )
Add acetaminophen 1000mg PO/IV
if not given yet
Reassess every 10 minutes
Titrate as necessary (Fentanyl
0.5mcg/kg IV)
• Continue monitoring pain
• Contact physician if pain can’t be treated adequately or not acceptable to the patient
Pain management in the
emergency department
• Administer ice, elevation, and immobilization as indicated.
• Provide condition-specific treatment.
32

43. 04
Summary

44. • Pain is unpleasant sensory and emotional experience caused by tissue damage .
• Duration of acute and chronic pain is less than and more than 3 months, respectively .
• Pain can be nociceptive which includes visceral and somatic pain or neuropathic arising from CNS and PNS.
• Clinical assessment of pain includes history in which we ask about the characteristics of pain (SOCRAT ) ,
physical examination including pain score and Investigations according to the system affected.
• Control of pain according to WHO analgesic ladder depends on whether the pain is acute or chronic and as well
as according to the severity of pain.
• The method of pain management either regular analgesia or PRN medications
• For mild pain we start with simple analgesics such as paracetamol and NSAIDs, for more severe pain we start
with both simple analgesics and opioids such as tramadol.
• Adjuvant drugs for management of side effects are necessary
• For chronic pain and neuropathic pain we add other adjuvant drugs such as antidepressants and anticonvulsant
• Interventional treatment of pain can be the alternative method for chronic pain not acceptable to the patient or
not relieved adequately by medical treatment.
• Pain monitoring is essential especially in admitted patients.
Summary
33

45. 05
Resources

46. Resources
1. https://www.amboss.com/us/knowledge/Pain_management
2. https://emedicine.medscape.com/article/310834-treatment?src=mbl_msp_android&ref=share
3. Mahmoud Sewilam book, Kasr Alainy school of medicine, Cairo university.
4. OXFORD HANDBOOK OF PAIN MANAGEMENT
5. https://www.hopkinsmedicine.org/health/conditions-and-diseases/nerve-blocks
34

47. Than
ks