"Pain Management in Chronic Wound" workshop for nurses

1. Pain Medicine
Saeid Safari, MD
Anesthesiologist,
Iran University of Medical Sciences

2. Sir William Osler, the eminent
19th-century clinician

3. What is the Pain?

4. Medical Definition:
“Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage.”
International Association for the Study of Pain, 1979
“An unpleasant sensation induced by noxious stimuli and
generally received by specialized nerve endings.”
CancerWEB, 2011

5. Operative Definition:
“Pain is whatever the experiencing person says it is,
existing whenever he/she says it does.”
Margo McCaffery, 1999

6. Epidemiology

7. Epidemiology
•
50 million people are partially or totally disabled due to pain
•
70 to 90% of patients with advanced disease from cancer have
significant pain that requires the use of opioid drugs.
•
Severe, unrelenting pain interferes with patients' quality of life,
including their activities of daily living, their sleep, and their social
interactions.

8. Epidemiology
•
80% of elderly patients have chronic pain.
•
66% have pain in the last month of life
• ~ ½ of hospitalized patients with pain are under-medicated.
•
Up to 50% of patients who are taking pain medication do not
experience adequate relief

9. Economics
•
Chronic pain causes 700 million lost work days/year in the U.S.
•
> $ 9 billion per year on OTC pain products.
•
Estimated cost of pain is $150 billion per year

10. Physiologic Effects of Pain
•
Immune System
•
Developmental
•
Future Pain
•
Quality of Life
•
Endocrine & Metabolic
•
Musculoskeletal
•
Cardiovascular
•
GI/GU

11. Psychiatric Disorders in Chronic Pain

12. •
Chronic pain is often comorbid with psychiatric disorders.
•
The typical finding is an increased occurrence of psychiatric
disorders among persons with a specific pain condition when
compared with persons with no pain.
•
Depression is the most commonly studied psychiatric disorder in
the context of chronic pain.

13. •
A higher occurrence of major depressive disorder among persons
with chronic pain.
•
The association of pain with anxiety disorders
•
A higher level of disability is often associated with comorbid
depression and anxiety disorders

14. •
Other than depression and anxiety, somatoform disorders,
substance use disorders, and personality disorders have all been
found to be more common among patients with chronic pain
compared with those without chronic pain
•
Posttraumatic stress disorder (PTSD) has received particular
attention in the literature.

15. Pain Behaviors

16. Reactions to Pain
1.
Somatic Motor Reactions
2.
Autonomic Reactions
3.
Emotional and Psychogenic Reactions
4.
Hyperalgesia

17. 1) Somatic Motor Reactions
•
Excess neuromuscular excitability throughout the body.
•
Withdrawal Reflexes.
•
Immobilization Reaction.
•
Guarding Reaction.

18. 2) Autonomic Reactions
•
Mild Cutaneous pain
• a pressor reaction = rise of blood pressure and heart rate, mediated
by sympathetic stimulation.
•
Sever cutaneous, deep and visceral pain
• a depressor reaction associated with hypotension, bradycardia, and
nausea, due to parasympathetic stimulation.
• Such pain is often described as sickening pain and may be
accompanied by vomiting.

19. Autonomic Response to Pain
•
Grimacing
•
Restlessness
•
Guarding
•
Increased respirations
•
Increased heart rate
•
Increased blood pressure
•
Diaphoresis

20. 3) Emotional and Psychogenic Reactions
•
Anxiety, fear, crying, depression, as well as the feeling of being hurt
may be felt by the pained person.
•
These reactions vary:
- From person to person on exposure to similar pain stimuli
- in the same person according to his emotional state

21. 3) Emotional and Psychogenic Reactions
1.
Worry about the cause of pain augment the feeling of pain.
• Thus, Patients suffer than healthy subject to the same degree of
pain.
2.
Strong emotional excitement & sever physical exertion may block
the feeling of pain.
• Thus, seriously wounded soldiers in a battlefield suffer little or
no pain till the battle is over.

22. Four Types of Pain Behaviors
•
Facial/audible expression of distress
•
Distorted ambulation or posture
•
Negative affect
•
Avoidance of activity

23. Emotions, Coping, and Pain
•
Higher levels of
1.
2.
Anxiety and Stress,
3.
Fear,
4.
Sadness,
5.
•
Depression
Anger
Fewer observable outward physical changes/signs.

24. 4) Cutaneous Hyperalgesia
Increased skin sensitivity to pain.
1- Primary Hyperalgesia
2- Secondary Hyperalgesia
- Develop 30-60 min. after injury.
Develops later.
- Lasts for several hours or days.
- Shorter duration than 1ry.
- In the area of redness.
- Non-painful stimuli (as touch)
becomes painful.
- In healthy skin surrounding red area.
- Pain is felt more sever than normal.
Mechanism:
Central sensitization explained by
Decreased pain threshold due to local
convergence-facilitation theory.
axon reflex releasing substance P

25. Pain Terminology, Classifications, and
Pathophysiology

26. Definitions
•
An unpleasant sensory and emotional experience associated with
actual or potential tissue damage and modified by individual
memory, expectations and emotions.
•
Pain is whatever the experiencing person says it is.
•
Highly subjective, leading to under treatment

27. Types of Pain
1.
Acute (<6 months)
2.
Chronic (6 months <)

28. Acute pain:
•
lasts less than 6 months, subsides once the healing process is
accomplished.

29. Presentation of Pain
Acute
Chronic
•
•
Often obvious distress
•
Can be sharp, dull, shock-like,
tingling, shooting, radiation,
fluctuating in intensity, and
varying in location (occur in
timely relationship to noxious
stimuli)
•
•
Comorbid
conditions
usually present
Can appear to have
noticeable suffering
•
Can be sharp, dull, shock-like,
tingling, shooting, radiation,
fluctuating in intensity, and
varying in location (do NOT
occur in timely relationship to
noxious stimuli)
•
Symptoms may change over
time
•
Usually NO obvious signs
not
May see HTN, increased HR,
diaphoresis, pallor…
no

30. Acute Pain (Nociceptive)
• Somatic
• Superficial (nociceptors of skin)
• Deep [body wall (muscle, bone)]
• Visceral (sympathetic system; may refer to
superficial structures of same spinal nerve)

32. Acute Pain
• Travels into the spinal cord along the
appropriate nerve root.
• Nerve root splits into a front division
and a back division and carries pain
sensation to the CNS (spinal cord and
brain).
• Passed to a short tract of nerve cells
(interneurons), which in turn synapse
with a nerve tract that runs to the
brain .

33. Acute Pain
• Sent out to the rest of the brain,
connecting with thinking and
emotional centers.
• A modifier pathway from the brain
modifies pain at the synapses in the
back part of the spinal cord (acute
pain is decreased rapidly after tissue
injury).

34. Chronic pain:
•
Complex processes & pathology.
• Usually altered anatomy & neural pathways.
•
Constant & prolonged, > 6 months, sometimes for life.
• “Lasting longer than expected time frame”

35. Altered Neural Structure
•
Chronic pain accompanied by:
• Cortical Reorganization
• Brain Atrophy

36. Chronic Pain
1.
Malignant (cancer)
2.
Nonmalignant
• Neuropathic (nerve injury)
• Inflammatory (musculoskeletal)
• Mixed or unspecified
• Psychogenic

37. Peripheral Nerve Fibers Involved in Pain
Perception
•
A-delta fibers–small, myelinated fibers that transmit sharp pain
•
C-fibers–small unmyelinated nerve fibers that transmit dull or
aching pain.

38. Chronic Pain
•
Neuropathic:
• Severe pain disorder that results from damage to the central
and peripheral nervous systems.
• Centrally generated
• Peripherally generated
•
Inflammatory:
• Results from the effects of inflammatory mediators.

39. Chronic Pain Conditions
•
Neuralgia
• an extremely painful condition consisting of recurrent episodes of
intense shooting or stabbing pain along the course of the nerve.
•
Causalgia
• recurrent episodes of severe burning pain.
•
Phantom limb pain
• feelings of pain in a limb that is no longer there and has no
functioning nerves.

40. •
Schematic of cortical areas
involved with pain processing and
fMRI

41. Major Categories of Pain
1.
Nociceptive pain
(stimuli from somatic and visceral structures)
2.
Neuropathic pain
(stimuli abnormally processed by the nervous system)

42. Nociceptive Pain
•
Visceral Pain: Associated with internal organs.
• Nature: Crampy, pressure, deep, dull to sharp, diffuse, referred.
•
Somatic pain : Soft tissues/ myalgic.
• Nature: Dull to sharp, throbbing, achy, localized

43. Neuropathic Pain
•
Abnormal neural processing by the peripheral or central nervous
system.
•
Signals are amplified or distorted; Synapse receptor numbers are
altered; pathways not originally involved become involved
•
Patient Description of Neuropathic Pain:
•
Burning, electric, searing, tingling, and migrating or traveling.

44. Tracking the Path of Pain
•
Peripheral receptors
•
Neural pathways
•
Spinal Cord mechanisms & long tracts
•
Brainstem, thalamus, cortex & other areas.
•
Descending pathways.

45. Pain Gate Control
3
The sites of synapses along the pain
pathway are considered as gates through
which pain transmission can be facilitated
(if the gate is open) or blocked (if the gate
is closed).
2
The main pain gates are:
1- Spinal gate: at the SGR.
2- Brain stem gate: at the nuclei of
reticular formation.
3- Thalamic gate: At neurons of
PVLNT & intalaminar thalamic nuclei.
1

47. Pain Pathways:
1.
Painful Stimuli or tissue damage activate specialized nerve cells
(nociceptors), which in turn send pain signals to the spinal cord.
2.
Pain signals enter the dorsal horn of the spinal cord, where some are
increased or decreased by the interneuron before continuing up to the
brain.
3.
Thoughts, feelings and beliefs change the pain signals into the
individual’s experience of “PAIN".
4.
Certain parts of the brain generate signals that travel back down the
spinal cord to reduce or increase pain signals at the interneuron.

49. Sites of Action
Peripherally
(at the nociceptor)
Peripherally Local
anesthetics,
Medications
Cannabinoids, NSAIDs, Opioids, Tramadol, Vanilloid
receptor antagonists(i.e., capsaicin)
Anticonvulsants (except the gabapentinoids)
(along the nociceptive nerve)
Centrally
(various parts of the brain)
Acetaminophen Anticonvulsants (except the
gabapentinoids), Cannabinoids. Opioids, Tramadol
Descending Inhibitory
pathway in the spinal cord
Cannabinoids, Opioids, Tramadol, Tricyclic
antidepressants, SHRIs
Dorsal horn of the spinal
cord
Anticonvulsants, Cannabinoids, Gabapentinoids, NMDA
receptor antagonists, Opioids,. Tramadol, Tricyclic
antidepressants, SNRIs

55. Pain Assessment and Management

57. Let’s try an experiment….
 Have students take pen and place over nail bed and push. Describe
sensation to neighbour. All the same?
 Now try counting backwards from 10 while holding pressure on
nail bed. Is the pain as bad?

58. Patient Assessment
•
Assess and reassess
•
Use methods appropriate to cognitive status and context
•
Assess intensity, relief, mood, and side effects
•
Use verbal report whenever possible
•
Document in a visible place
•
Expect accountability
•
Include the family
•
Include past physician(s)
•
Get old records
•
Check for addictive personality

59. Patient Pain History
• Site(s)
• What makes it better/worse
• Quality
• Impact on sleep, mood,
• Severity
• Date of onset
• Duration
activity
• Effectiveness of previous
medication

60. PQRST mnemonic:
• P: Precipitating and palliating factors
• Q: Quality
• R: Region and radiation
• S: Severity
• T: Time

61. Instruments
• Single-dimension
• Visual analog scale
• Verbal numerical scale
• Verbal rating scale
• Multidimensional
• Assesses the pain as well as the emotional and behavioral effects
of the pain.

62. One type has faces—(Whaley & Wong, 198)

63. Other pain scales are just numeric

64. Single-dimension Instruments
Verbal rating scale
• No pain = 0
• Mild pain = 1-3
• Moderate pain = 4-6
• Severe pain = 7-9
• Worst ever = 10

66. Can pain-intensity scales be used ?
•
Yes- but, limited by cognitive changes, impaired vision, physical
limitation
•
no specific scale more “user friendly”
•
83% of nursing home residents could complete a pain scale

67. Why have a pain scale?
•
Sometimes hard to put words to pain
•
Pain is multi-faceted (How long? Where? How intense? What kind
feeling?
•
Visual scales help us understand where pain located.
•
Faces help us understand how pain makes patient feel.
•
Numeric scales help quantify pain using numbers.

68. Pain Management

69. Pain Management
Pharmacological &
nonpharmacological management

70. Principles of Treatment
•
Reduction of Pain:
• Behavioral, Meds, Blocks, Surgery, Complementary
• There is no magic bullet, no single cure
•
Rehabilitation:
• Reconditioning & Prevention
•
Coping:
• Management of Residual Pain

71. Treatment Objectives
•
Decrease the frequency and / or severity of the pain
•
General sense of feeling better
•
Increased level of activity
•
Return to work
•
Decreased health care utilization
•
Elimination or reduction in medication usage

72. Treatment of Pain
1.
Non-pharmacologic
2.
Medications
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Acetaminophen
• Antidepressants & anticonvulsants
• Adjuvants
• Narcotics
1.
Invasive procedures
Copyright © 2003 American Society of Anesthesiologists. All rights reserved

73. Nonpharmacological Management

74. Non-pharmacologic Pain Management
•
Neurostimulation
•
TENS
•
Acupuncture
•
Anesthesiology
•
Nerve block
•
Surgery
•
Physical therapy
•
Exercise
•
Heat/cold
•
Psychological approaches
• Cognitive therapies (relaxation,
imagery, hypnosis)
• Biofeedback
• Behavior therapy
• Psychotherapy
• Complementary tx
• Massage therapy
• Art therapy
• Music therapy
• Aroma therapy

75. Non-Pharmacologic
 Cognitive Behavioral Therapy: Yes, ‘A’, Cochrane
“Cortical plasticity related to chronic pain can be modified by
behavioral interventions that provide feedback to the brain areas
that were altered by somatosensory pain memories.”
H. Flor, 2002 & 03
“Individuals can gain voluntary control over … specific brain
region… these effects were powerful enough to impact severe,
chronic clinical pain.”
de Charms, 2005, Nat’l Acad Sci

76. Non-Pharmacologic
 Meditation: Yes, ‘A’, Cochrane
 Strong evidence for the use of relaxation & hypnosis in reducing pain in
a variety of medical conditions
 Music Therapy: Yes, ‘A’, Cochrane

77. Non-Pharmacologic
•
Pre-Op counseling: Yes, ‘B’, Cochrane
•
Ice: Yes, “B”, Cochrane
•
Chiropractic: No, ‘B’, Cochrane
•
Massage: Yes for cancer, low back & OA pain, ‘B’, Cochrane
•
Exercise : Yes; ‘B’, Cochrane

78. Non-Pharmacologic
•
Magnets: Don’t Know ‘I’, Cochrane
•
Spinal Cord Stimulation: Don’t know, ‘I’, Cochrane
•
Acupuncture: Don’t Know, ‘I’, Cochrane
•
TENS: Don’t Know, ‘I’, Cochrane

79. Acupuncture
•
Acupuncture has been practiced in China for more than 4000 years as a method for
pain relief.
Mechanism:
1- needles in appropriate body regions are thought to excite certain sensory neural
pathways which feed into the brain stem centers (such as the PAG) involved in the
pain control system, with release of endogenous opioid peptides.
2- simultaneous suppression of pain transmission at the spinal pain-gate by acupuncture

80. APA offers the following tips on coping with
chronic pain:
•
Manage your stress.
•
Talk to yourself constructively.
•
Become active and engaged.
•
Find support.
•
Consult a professional.

81. Manage your stress.
•
Emotional and physical pain are closely related, and persistent pain
can lead to increased levels of stress. Learning how to deal with
your stress in healthy ways can position you to cope more
effectively with your chronic pain. Eating well, getting plenty of
sleep and engaging in approved physical activity are all positive
ways for you to handle your stress and pain.

82. Talk to yourself constructively.
•
Positive thinking is a powerful tool. By focusing on the
improvements you are making (i.e., the pain is less today than
yesterday or you feel better than you did a week ago) you can make
a difference in your perceived comfort level. For example, instead of
considering yourself powerless and thinking that you absolutely
cannot deal with the pain, remind yourself that you are
uncomfortable, but that you are working toward finding a healthy
way to deal with it and living a productive and fulfilling life.

83. Become active and engaged.
•
Distracting yourself from your pain by engaging in activities you
enjoy will help you highlight the positive aspects of your life.
Isolating yourself from others fosters a negative attitude and may
increase your perception of your pain. Consider finding a hobby or a
pastime that makes you feel good and helps you connect with
family, friends or other people via your local community groups or
the Internet.

84. Find support.
•
Going through the daily struggle of your pain can be extremely
trying, especially if you’re doing it alone. Reach out to other people
who are in your same position and who can share and understand
your highs and lows. Search the internet or your local community
for support groups, which can reduce your burden by helping you
understand that you’re not alone.

85. Consult a professional.
•
If you continue to feel overwhelmed by chronic pain at a level that
keeps you from performing your daily routine, you may want to talk
with a mental health professional, such as a psychologist, who can
help you handle the physical and psychological repercussions of
your condition.

86. Using psychological factors in clinical practice

87. Vigilance to pain
•
Patients are distorted by the pain and are urged to react. Pain
patients will have impaired concentration as they are being
interrupted constantly by an aversive stimulus. Keep all
communications clear and brief. Repeat key points often. Expect
patients to talk about the pain often, as it is being brought
repeatedly into attentional focus for them. This is not a sign of a
somatization disorder or hypochondria.

88. Avoidance
•
Patients will naturally avoid pain and painful procedures. Be aware
that this will occur and plan for it. Painful treatments will be
avoided and patients will compensate for any disability caused by
avoidance (e.g. shifted body weight distribution. ¡f a habitual
pattern of avoidance develops, this may lead to chronic pain.
Patients must be given an understanding that pain does not
necessarily equal damage. A credible medical authority must deliver
this message.

89. Anger
•
Patients with pain may shout at you, abuse you and generally be
hostile to you. If they are hostile to you they have probably been
hostile to everyone. Most often this will have nothing to do with
you. and you will need to understand that anger normally means
extreme frustration, distress and possibly depression. Anger
functions to push people away and isolate a person. The angry pain
patient is therefore less likely to have received or heard any
information about their problems and be more confused than the
non-angry patient.

90. Involve the patient
•
First, assess the patient’s normal way of coping with pain by simply
asking how he or she has coped with predictable pain, such as a
visit to the dentist. Secondly, match your strategy to the patient’s
preference. ¡f the patient needs information, inform them how much
pain they may expect to feel, what it may feel like and, critically, for
how long (if this information is known). Always slightly
overestimate the time rather than underestimate it. Finally, if
possible. involve the patient in the delivery of any pain management
strategy.

91. Make sense of the pain
•
Always ask the patient what they know and fear about the cause of
the pain, the meaning of the pain and the time course of the pain.
Expect the unexpected. What makes sense to one person is
nonsense to another. What matters is that it is their understanding,
not yours, that will inform their behaviour. Uncertain diagnoses or
unknown diagnoses will lead to increased vigilance to pain and
increased symptom reporting.

92. Consistency
•
Develop a consistent approach to clinical information, patient
instruction and patient involvement within pain management.
Practice should be consistent for each patient and from each
member of the pain team, over time.

93. Pharmacological management:

94. Using Pharmacological Options Safely
•
Pharmacokinetics
•
Pharmacodynamics
•
Compliance
•
Cost
•
Polypharmacy

96. Modified WHO 3- Step Analgesic Ladder
Quality of Life
Proposed 4th Step
Invasive treatments
Pain
Severity
Opioid Delivery
Pain persisting or increasing
Step 3
Opioid for moderate to severe pain
± Nonopioid ± Adjuvant
8 -10
Pain persisting or increasing
The WHO
Ladder
Step 2
Opioid for mild to moderate pain
± Nonopioid ± Adjuvant
4-7
Pain persisting or increasing
Step 1
± Nonopioid
± Adjuvant
Pain
Deer, et al., 1999
1-3

97. •
Step 1: non-opioid analgesics
• (COX-2, Aspirin, Acetaminophen, Diclofenac, Ibuprofen, Tenoxicam,
Panadeine, Nurofen.
•
Pain rating 1-2-3)
Step 2: mild opioid is added (not substituted) to step 1
• (Codeine, Propoxyphene, Tramadol, Sevredol, DHC Continus,
Dihydrocodeine tartate.
•
Pain rating: 4-5-6)
Step 3: Opioid for moderate to severe pain is used and titrated to effect
• Oxycodone, Morphine, Fentanyl, Pethidine, Ketamine Pain rating 7-10

98. Remember basic principles:
• Use WHO pain ladder
• Take a careful drug history
• Know the pharmacology of the Rx
• “Start low, go slow”
• Regularly review the regimen
• Remember that drugs may cause illness

99. Pharmacological management:
•
Selection of appropriate drug, dose, route and interval
•
Aggressive titration of drug dose
•
Prevention of pain and relief of breakthrough pain
•
Use of coanalgesic medications
•
Prevention and management of side effects

100. Patient Controlled Analgesia (PCA)

101. Pharmacology of Nociception
Four Steps:
1. Transduction
• NSAIDs, Local Anesthetics & Anticonvulsants
2. Transmission
• Opioids, NMDA Antagonists
3. Perception
• Distraction, Relaxation, Imagery
4. Modulation
• Tricyclic Antidepressants, Opioids, GABA Agonists

102. Manage side-effects opiates:
• Constipation
• Tolerance to nausea and sedation develops in 3-7 days.
• Use adjuvant (coanalgesic) agents with opioid:
• Tricyclic antidepressants
• Corticosteroids
• Anticonvulsants
• Muscle relaxants
• Stimulants

103. Physical Dependence
•
A process of neuro-adaptation
•
Abrupt withdrawal may → abstinence syndrome
•
If dose reduction required, reduce by 25-50% q 2–3 days; avoid
antagonists.

104. Tolerance
•
Reduced effectiveness to a given dose over time.
•
If dose is increasing
• suspect opioid tolerance
• disease progression
• psychological/spiritual pain

105. Addiction
•
Acceleration of abuse patterns onto a primary illness.
•
Characteristics:
• Psychological dependence
• Compulsive use
• Loss of control over amount and frequency of use
• Loss of interest in pleasurable activities
• Continued use of drugs in spite of harm

106. Pseudoaddiction
•
Drug seeking behavior associated with a person’s need to relieve
pain and suffering, not an obsession with the mood altering affects
of medication.
Wesson et al, 1993

107. Chronic Pain Medical Issues
•
Physical Exam
•
History documenting prescribing rationale
•
Pain assessment documentation

108. Legal Issues
• Accurate prescription records
• Controlled substance laws
• Schedule
• Emergency Telephone Prescriptions
• Nursing Home Patients Fax prescriptions

109. Skilled Prescribing
•
Patient –Physician Partnership
•
Pain management expectations
•
Medication responsibilities
•
One physician
•
One pharmacy

110. Role of Invasive Procedures
•
Optimal pharmacologic management can achieve adequate pain
control in 80-85% of patients
•
The need for more invasive modalities should be infrequent
•
When indicated, results may be gratifying

111. Role of Invasive (“Anesthetic”) Procedures
• Intractable pain*
• Intractable side effects*
*Symptoms that persists despite carefully individualized
patient management

112. What about the 20% who do not get relief
from the WHO ladder
•
Has a true pain assessment been accomplished?
•
Have you examined the patient?
•
Is the pain neuropathic?
•
Is the patient receiving their medication?
•
Is the medication schedule and route appropriate?
•
Have the opioids been titrated aggressively?
•
Have invasive techniques been employed?

113. What about the 20% who do not get relief
from the WHO ladder
•
Lastly,
•
Cosider checking a vitamin D level :
•
There is an association between Vitamin D levels & chronic pain in
women.
•
Women with levels of 75 – 99 nmol/L had less pain.
•
Ann Rheum Dis. August 12, 2008.

114. Importance of Teamwork
•
Complex chronic pain, especially if caused by life-threatening
disease, is best treated by a team.
•
The diverse talents of physician, nurse, social worker, chaplain,
working together offers comprehensive control of physical,
emotional, and spiritual pain.
•
Palliative care is for ALL patients who are suffering.

115. So, what about “Pain Clinics”
•
Depends on where you live and of what they consist.
•
“Most” are not teams, but 1 or more anesthesiologists.
•
Most
• Want to do invasive procedures
• Prefer not to manage chronic medications
• Do
NOT
have
practitioners
Psychologists
nor
alternative
medical