Pain management

1. MANAGEMENT of
PAIN
Prepared by : Yahya Farwan.
Supervised by : Dr. Muneer Bashaaib.
University of science and technology hospital, Sana’a, Yemen, 2023

2. 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 6
2.2 Clinical Examination 7
2.3 Investigations 8
3.1 WHO analgesic ladder 9
3.2 Oral analgesics 12
3.3 Parenteral analgesics 15
3.4 Analgesic suppositories 17
3.5 Adjuvant analgesics 18
3.6 Management of side effects . 20
3.7 Topical analgesics 21
3.8 Interventional treatment 22
3.9 Additional methods for management of pain 23
1. Overview
.
2 Clinical Assessment of Pain
.
3 Control of Pain
4. Resources 24
I

3. 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
II

4. Overview of the Pain
01

5. 1.1 Definitions of Pain
● Painis an unpleasantsensory and emotional experience arising from actual or
potential tissue damage, or described in terms of such damage.
● Acute pain: a warning signal indicating actual or potential tissue damage that
triggers a protective reaction with durationof less than 3 months.
● Chronicpain: pain that lasts beyond the normal tissue healing time
(3 months) , unlike acute pain, chronicpain has no protective role in
preventing further tissue damage and can be considered a disease entity in its
own right.
● Painis always subjective. (
1
)
1

6. Nociceptorsin superficial and deep
structures➡️ Post. Root ganglion
SGR in the posteriorhorn cell of the
spinal cord
➡️ Cross to oppositeside
➡️ Ascend in the lateral spinothalamictract
➡️ lateral lemniscus in the brainstem
➡️ thalamus
➡️ area 1, 2, 3 in parietal lobe
➡️ ends in the cortical sensory area of
oppositeside. (
3
)
1.2 Pain Pathway
2

7. 02
Types of Pain

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)
:
1.3 Types of Pain
4

10. 03
Clinical assessment of Pain

11. 2.1 History Taking:
• Site location of the pain helps in targeting the therapy to the right place.
• Onset sudden onset serious cause.
more gradual and diffuse pain nonserious cause.
• Severity
• Mild pain : Doesn’t interferewith most activities, pt able to adapt to pain
psychologically and with medications.
• Moderate pain : Interferewith many activities, require lifestyle change but
the patient is independent, pt unable to adapt pain.
• Severe pain : Unable to engage in normal activities, pt is disabled and unable
to function independently.
• Duration distinguishing acute from chronic pain.
• Frequency The frequency of pain may provide a clue to the diagnosis.
ClinicalAssessment of Pain
5

12. 2.1 History Taking:
• Nature throbbing and pulsatile pain vascular involvement ,while burning and
shooting types are seen in neuropathic pain.
• Aggravating and RelievingFactors
• Associatedsymptoms
• Previousinterventions:treatment, invx, …(1)
• 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
ClinicalAssessment of Pain
6

13. 2.2 Physical Examination
• General observation
• Blood Pressure • Heart Rate • Respiratory Rate • Temperature
• Pain score — should be recorded as a vital sign :
The numerical rating scale
The visual analog scale
Wong–Baker faces pain scale. (1)
ClinicalAssessment of Pain
7

14. 2.3 Investigations
• Laboratory:
• Routine invx : CBC, blood culture, ESR and CRP, LFT, RFT, S. electrolytes
• Specific invx :according to system affected.
• Imaging :
• according to system affected:
X-ray , ECHO, ECG, US, MRI , CT.
ClinicalAssessment of Pain
8

15. 03
Control of Pain

16. Mild opioids
Strong opioids
Step I : Mild Pain
Step II : moderatePain
Step III : severe Pain
3.1 WHOanalgesicladder
The WHO analgesic ladder is a 3-step algorithm for the management of acute and
chronic pain.
Controlof Pain
9

17. Modified WHO analgesic ladder
Controlof Pain 10

18. WHO analgesicladder
The WHO analgesic ladder is a 3-step algorithm for the management of acute and
chronic pain as follow:
Regular analgesic (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.
Appropriate PRN medication
• Short-acting analgesics for peaks in pain
• If PRN medication is required ≥ 3×/day → inadequate analgesia likely;
review the regular medication.
Controlof Pain 11

19. 3.2 Oral analgesics
1. Non-opioids:
A. Acetaminophen 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.
Controlof Pain 12

20. Important notes about oral non-opioid analgesics
A. NSAIDs:
1. Ibuprofen and naproxen are the preferred first-line analgesics for mild to moderate pain.
2. Use with caution in patients with PUD and renal disease.
3. Avoid NSAIDs, if feasible, in patients with bleeding disorders and those who will soon
undergo surgery or an invasive procedure.
4. Contraindicated in patients with a recent MI and in the perioperative period
of CABG (exception: low-dose aspirin in the management of acute MI)
B. Selective COX-2 inhibitor:
• 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
Controlof Pain
3.2 Oral analgesics
13

21. 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. Combinationanalgesics:
Consider combination analgesics for the management of moderate to severe pain.
Codeine/acetaminophen 300 mg1 to 2 tablets PO every 4 hours PRN
Codeinephosphate/cetaminophen 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
Controlof Pain
3.2 Oral analgesics
14

22. 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 sulfate 0.1–0.2 mg/kg IV every 4 hours as needed or 10 mg IM every 4 hours PRN
Fentanylcitrate 0.35–0.5 mcg/kg IV every 30–60 minutes as needed (intermittent dosing)
Hydromorphone hydrochloride 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
Controlof Pain 15

23. Important Notes about opioids:
1. Combine with nonopioidanalgesics (multimodal pain control)to minimize the
dose needed for analgesia)
2. Monitorfor respiratory depression in the first 72 hours after initiating or
increasing the opioid dose.
3. Tramadol is not recommended in patientswith epilepsy, as it lowers the seizure
threshold.
4. Contraindicatedin:
Bronchial asthma
Respiratory depression
Bowel obstruction
Biliary colic.
3.3 Parenteral analgesics
Controlof Pain 16

24. 3.4 Analgesic suppositories
Consider as an alternative when oral medicationis 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.
Controlof Pain 17

25. 1. Anticonvulsants
are 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).
2. Musclerelaxants
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)
3.5 Adjuvant analgesics
Controlof Pain 18

26. 3. 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
Clomipramine 25–250 mg PO once dail
Duloxetine 30–60 mg PO once daily
Controlof Pain
3.5 Adjuvant analgesics
19

27. 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
Controlof Pain 20
3.5 Adjuvant analgesics ) Management of side effects(

28. 1. Lidocaines:
Lidocaine patch 5% : used in postgerpetic 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 epolamine 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.
Diclofenacsodium 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
Controlof Pain 21

29. 3.8 Interventional Treatment
Nerve block:
Nonsurgical nerve blocks:
• Epidural analgesia or anesthesia.
• Spinal anesthesia or analgesia.
• Peripheral nerve blockade. (5)
Surgical nerve blocks:
• Sympathetic blockade: used to treat visceral, vascular, and neuropathic pain.
Can be performed by injecting neurolytic substances, radiofrequency
denervation or cryoneurolysis of sympathetic nerves.
• Neurectomy. A damaged peripheral nerve is surgically removed.
• Rhizotomy. removal of the root of the nerves that extend from the spine. (
5
)
Controlof Pain 22

30. Physical therapy
• Massage
• Thermotherapy
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
Occupational and Recreational Therapy
Vocational Therapy (
2
)
3.9 Additional methods for pain management
Controlof Pain 23

31. 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 PAINMANAGEMENT
5. https://www.hopkinsmedicine.org/health/conditions-and-diseases/nerve-blocks
24

32. Thanks