The correct response is to c) call the anesthesiologist for pain assessment. If the epidural is not providing adequate pain relief over time, the anesthesiologist needs to be notified to assess the epidural and make adjustments if needed. Comforting the patient without addressing the increasing pain is not appropriate care.

1. The Need to Understand Pain
and its Management
Prepared and presented by:
Soha Adloni
MSc Clinical Pharmacy

2. Objectives:
 1. Pain definitions & overview
 2. Pain pathway & classification
 3. Pharmacological Treatment of Acute Pain
 4. Choice of Drugs in Treatment of Acute /
Chronic Pain
 5. Conclusion

3. 1. Pain Definitions
 "Pain" is defined by IASP*: "an unpleasant sensory and
emotional experience arising from actual or potential
tissue damage or described in terms of such damage“
 Pain: the least stimulus intensity at which a subject
perceives pain.
 Margo McCaffery (1968)first defined pain: "whatever the
person experiencing says it is, existing whenever he says
it does.”
 Favorite definitions:
- whatever the patient thinks it is at the present
time.

4. 1. Pain Definitions
 Analgesia: Absence of pain in response to
stimulation which
would normally be painful (e.g. using
drugs)
 Nociceptor: A sensory receptor of the peripheral
(somatosensory nervous system) that
transmits
noxious stimuli to CNS.
 Noxious stimulus: A stimulus that is damaging or
threatens damage to normal tissues
(chemical,
mechanical, thermal)
 Pain threshold: The minimum intensity of a stimulus
that is

5. 1. Pain Overview
Factors affecting pain perception
AGE MEANING
CULTURE OF PAIN
PAIN
Pain Control EXPERIENCE ATTENTION
Sex
Anxiety

6. 2. Pain Pathway

8. 2. Pain classification
Diagnostic classification
A. Nociceptive pain
I. Somatic: well localized; e.g. skin, bones
II. Visceral: poorly localized; e.g. organs
B. Neuropathic pain
I. Central: Localized and diffused; burning, stabbing pain
e.g.
CNS
II. Peripheral: localized neuropathies
C. Idiopathic pain
usually in head, shoulders, or pelvic areas

10. 2. Pain classification
Clinical types
Acute pain Chronic pain
 Results from noxious  Results from:
stimuli that activates nociceptors, visceral, or
nociceptors neuron somatic
 It accompanies surgery,
traumatic injury, tissue  It accompanies chronic
damage, and inflammatory disease, untreated
processes. condition.
 Self-limited, resolves
over days to weeks, but
 Unresolved as long as
can persist for 3 months
underlying cause is
 Treatment is short term present.
and curative

11. Acute Pain
 Goals:
1. provide analgesia
2. lessen side effects of analgesics
3. Minimize the dose of medication
 Effective Pain control
1. Early mobilization
2. Shorter hospitalization
3. Reduce costs
4. Increase patient satisfaction
 Analgesics:
1. Multimodal analgesics, preemptive analgesia
2. Parenteral, PCA, Epidural
3. ATC first 24 hrs post surgery, then prn

12. Anxiety
Increase
hospitalization Family
and costs worries
If pain is inadequately
controlled, what are the
consequences?
Medication
Depression
worries
Impaired Sleep
ambulatio disturbances
n

13. What is the pain score for this player?
 Pain is whatever the patient thinks it is at the
present time.
 Pain is always subjective to the patient’s report

14. 3. Pharmacological Treatment of Pain
A B C
Non- Opioids Adjuvants
Opioids

15. 3. Pharmacological Treatment of Pain
A- Non-Opioids
 Paracetamol (Panadol): PO, IV. Act centrally &
peripherally
max. daily dose: 3gm of OTC meds, 4 gm
IV.
Cox-1,

Cox-2 Non-steroidal Anti-inflammatory Drugs (NSAIDs)
inhibitor Ketorolac (Toradol)- inj
s
Ibuprofen (Advil, Neurofen, Brufen)
Diclofenac Na/K (Voltaren, Olfen, Cataflam)
Mefanemic acid (Ponstan)
Cox-2 Naproxen (Naprosyn)
inhibitor
s
Celebrex (Celecoxib)
Etoricoxib (Arocoxia)

16. 3. Pharmacological Treatment of Pain
A- NSAIDs mechanism of action

17. 3. Pharmacological Treatment of Pain
A- NSAIDs
Ketorolac (Toradol):
 Postoperatively for max 5 days
 Reduce amount of opioid requirement, reduce
S.E’s
 Dose= 15 – 30 mg IV / IM Q6hrs
Cox-2 inhibitors:
 Effective anti-inflammatory in arthritis
 Carry cardiovascular risk warning
 Less GI S.E’s

18. 3. Pharmacological Treatment of Pain
A- NSAIDs
Side effects:
 Prolong bleeding time
 Gastric erosions/ ulceration/ perfusion
 Affect kidney function:
_ Water / electrolyte balance
_ Interfere with diuretics/ antihypertensive
_ Renal injury / nephrotic syndrome

19. 3. Pharmacological Treatment of Pain
B- Opioids
Oral, Rectal, IV, IM, SC, Equianalgesic
Morphine pca, Epi, potency
10 mg IM
Meperidine IV, IM, pca, Epi 75 mg
(Pethidine)
IV, Epi, pca, Transdermal 100 mcg
Fentanyl patches, sublingual
lollipops
Codeine Oral, Rectal, IV, IM. 130 mg
(Solpadeine: codeine
8mg/Aceta./caffeine)
Oral, IV, SC, IM, Rectal, 1.5 mg
Hydromorphone pca
Tramadol Oral, IV, IM, SC 100 mg
(Tramal)

20. B- Opioids / Narcotic analgesics
 Morphine: Gold standard opiate
Bolus: 2-5 mg slowly over 5min (Q 1-3 hrs).
CI: 1mg/hr titrated to the desired analgesic effect.
IM; 5-10 mg (Q3-4 hrs).
SC: not recommended in repeated dose.
 Meperidine: used in acute pain only, alternative for morphine
intolerance.
limited use due to toxic metabolite, sedative, and emetic
effect.
 Fentanyl: 100 times more potent, rapid onset of action
given bolus, CI, oral, patches.
 Tramadol:
Acts on opioid & non-opioid receptors (moderate pain)

22. B- Opioids Side Effects
 Nausea and vomiting
 Constipation
 Pruritis
 Irritable movement
 Psychomimetic effects
 Sedation
 Broncho-constriction
 Respiratory Depression
N.B: If respiratory depression/sedation develops, the nurse must be
familiar with administration of Naloxone, which will reverse the effect
. Naloxone is diluted (0.4 mg in 10 mL NS) every 1-2 min until the
patient's respiratory status improves and the patient starts to
arouse.

23. 3. Pharmacological Treatment of Pain
C- Adjuvants
Agents used to induce analgesic effect indirectly
 Local anesthetics
 Antidepressants
 Anticonvulsants
 Corticosteroids
 Muscle relaxants
 Anti histamines

24. 4. Choice of Drugs in Treatment of Acute /
Chronic Pain

25. 4. Choice of Drugs in Treatment of
Acute / Chronic Pain

26. 4. Choice of Drugs in Treatment of
Acute / Chronic Pain
1) Severity of pain
2) Routes of administration
3) Patient information
4) Pharmacokinetic of drug
5) Patient’s preference

27. 5. Conclusion
 If pain is not controlled effectively, it can result in
negative physiologic and psychological
consequences. Nurses must learn how to properly
assess pain and how to optimize safe pain
management for all patients in their care.
 Frequency/ routes of administering analgesics are
highly significant in treatment:
- Opioid ATC vs. prn in the first 24 hrs post surgery
- Analgesics could be given in incidental pain
- IV vs. SC vs. IM
 Opioids can be titrated upward for maximum efficacy,
but are limited by their side effects.

28. 5. Conclusion
 The administration of Opioid + non-opioid
promote co-analgesic effect (reduced doses,
lessen S.E’s).
 Acute pain can activate the sympathetic branch
producing : hypertension, tachycardia,
diaphoresis, shallow respiration, restlessness,
facial grimacing, pallor, and pupil dilation
 Addiction is so rare when Opioids are taken for
medical reasons.

29.  Case1:
Post operative (sleeve) patient , ordered for morphine 3mg
Q4 hrs, perfalgan 1g Q6hrs. Patient received 2 doses of
morphine, and 4 doses of perfalgan during the first 24 hrs;
but still in pain, what is the cause of his pain?
a. Patient is complainer & will be fine in few hours
b. Need different analgesic than morphine
c. Morphine was given prn not ATC
d. Patient is sedated and can not be assessed probably
Pain assessment for effective pain control:
a. Pain score 4 – 7
b. Multimodal analgesic (opioid + non-opioid)
c. Morphine should be given ATC
d. Pain assessment should be done appropriately

30.  Case 2:
LSCS patient is receiving Epidural in the first 24hrs. Pain is
increasing with time, but nurse keeps comforting patient
that “it will go away”. The correct nurse’s response should
be:
a. Check the epidural catheter site
b. Check the epidural pump
c. Call the anesthesiologist for pain assessment
d. Assess the patient for pain score over time
Pain assessment for effective pain control:
a. Pain catheter could be dislocated
b. Epidural pump may not be delivering medication
c. Anesthesiologist is called if needed
d. Pain is “whatever the patient thinks it is at the present time”

31.  Case 3:
Patient with moderate - sever pain was ordered for morphine
5mg Q4hrs, perfalgan 1 g Q6hrs. Patient was requesting pain
killers due to constant pain around the clock, but nurse
administer morphine 1mg Q4hrs instead because of fear of
addiction. What are the consequences of this action on
patient’s pain control?
a. Reducing the dose will reduce addiction possibilities of
morphine
b. Pain will increase with time
c. Patient’s pain is tolerable and will decrease as soon as he
mobilize
d. Physician will be glad that the nurse has taken this action
Pain assessment for effective pain control:
a. Addiction is so rare when Opioids are taken for medical
reasons.