The document provides information on pain management. It begins with an introduction that defines pain and discusses its prevalence. It then classifies pain as either acute or chronic, and further divides chronic pain into malignant and non-malignant. The document describes different types of pain including somatic, visceral, bone, and neuropathic pain. It also discusses pain assessment tools and treatment approaches, including pharmacological and non-pharmacological options. The goals of pain management therapy and WHO pain management ladder are also summarized.

1. PAIN
MANAGEMENT
Dr. Sameh Ahmad Muhamad abdelghany
Lecturer Of Clinical Pharmacology
Mansura Faculty of medicine

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CONTENTS
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5
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PAIN
ASSESSMEN
T
TREATMENT
INTRODUCTION
CLASSIFICATION
TYPES

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1 INTRODUCTION

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Introduction
 Definition : An unpleasant sensory and
emotional experience associated with
actual or potential tissue damage.
 Pain may not be directly proportional to
amount of tissue injury.
 Highly subjective, leading to
undertreatment

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 In cancer, the prevalence of pain in
advanced disease is 70-90%.
 " In HIV disease, pain prevalence is
about 50%.
 " Other illnesses may have significant
pain but no clear data.

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2 CLASSIFICATION

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Classification
I. Acute
II.Chronic :
i. Non malignant
ii. Malignant

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 Injury, trauma, spasm or disease to skin, muscle, somatic
structures or viscera;
 Perceived and communicated via peripheral mechanisms
(pathways)
 Usually associated with autonomic response as well
(tachycardia, blood pressure, diaphoresis, pallor,
mydriasis (pupil dilation).
Acute Pain

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 Usually subsides quickly as pain producing stimuli
decreases
 Associated with anxiety-(decreases rapidly)
 Can be understood or rationalized as part of the healing
process.
Cont.

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i. Non-malignant
 Pain persists beyond the precipitating injury
 Rarely accompanied by autonomic symptoms
 Sufferers often fail to demonstrate objective
evidence of underlying pathology.
 Characterized by location-visceral, myofacial, or
neurologic causes.
II. Chronic Pain

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ii. Malignant
 Has characteristics of chronic pain as well as
symptoms of acute pain (breakthrough pain).
 Has a definable cause, e.g. tumor recurrence
 In treatment, narcotic habituation is generally
not a concern.
II. Chronic Pain

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3 TYPES OF PAIN

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 Types of Pain
 Somatic
 Visceral
 Bone
 Neuropathic
 Emotional/Spiritual

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I- Somatic Pain
 Aching, often constant
 May be dull or sharp
 Often worse with movement
 Well localized
 Skin, Muscle, Joints, superficial or deep.
 Eg:
o Bone & soft tissue
o chest wall

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II- Visceral Pain
 Constant or crampy
 Aching, burning
 Poorly localized
 Referred
 Organs of Thorax & Abdominal Cavity.
 Usually as a result of stretching, infiltration and
compression
 Eg:
o Liver capsule distension
o Bowel obstruction

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 Both Somatic & Visceral pain
travel along the same
pathways. Pain stimuli arising
from the viscera is perceived
as somatic in origin.
 This can be confused by the
brain and is often described as
referred pain.

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III- Bone Pain
 Poorly localized, aching, deep, burning.
 Common with malignancy of Breast, Lung,
Prostate, Bladder, Cervical, Renal, Colon,
Stomach and Esophagus
 Can lead to pathological fractures.
 Vertebral Metastases can lead to cord
compression.

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IV- Neuropathic Pain
 Caused by disturbance of function or pathological
changes in a nerve.
 May arise from a lesion or trauma, infection,
compression or tumour invasion.
 Described as burning, shooting, tingling.
 Does not respond well to standard analgesics.

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 Categories of Pain
 Classified by inferred pathophysiology:
I. Nociceptive pain (stimuli from somatic and
visceral structures)
II. Neuropathic pain (stimuli abnormally
processed by the nervous system)

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I. Nociceptive:
 Caused by invasion &/or destruction &/or pressure on
superficial somatic structures like skin, deeper skeletal
structures such as bone & muscle and visceral structures
and organs.
 Types: superficial somatic, deep somatic, & visceral.

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II. Neuropathic:
 Caused by pressure on &/or destruction of peripheral,
autonomic or central nervous system structures.
 Radiation of pain along dermatomal or peripheral nerve
distributions.
 Often described as burning and/or deep aching &
associated with dysesthesia or lancinating pain.

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Effects of pain
 Sympathetic responses
o Pallor
o Increased blood pressure
o Increased pulse
o Increased respiration
o Skeletal muscle tension
o Diaphoresis

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Effects of pain
 Parasympathetic responses
o Decreased blood pressure
o Decreased pulse
o Nausea & vomiting
o Weakness
o Pallor
o Loss of consciousness

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4 Pain Assessment

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Pain History
 The site of pain
 Type of pain
 Exacerbating & Relieving factors
 How frequently
 Impact on daily life

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Pain History
 Other important additional questions to be asked.
o What is the response to past and current analgesic
therapy?
o Any kind of diary or record about the pain?
o Fears they have about analgesics?

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PAIN ASSESSMENT Tools
 Verbal Analogue Scales.
 Visual Analogue Scales.
 The Faces Scale

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Factors to consider in choosing a
pain scale
1. Age of patient
2. Physical condition
3. Level of consciousness
4. Mental status
5. Ability to communicate

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Numeric Pain Rating Scale
 Ask the patient to rate their pain intensity on a scale
of 0 (no pain) to 10 (the worst pain imaginable).
 Some patients are unable to do this with only verbal
instructions, but may be able to look at a number
scale and point to the number that describes the
intensity of pain.

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Numeric Pain Rating Scale

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Wong-Baker FACES Pain Rating
Scale
 Can be used with young children (sometimes as young as 3 years
of age)
 Works well for many older children and adults as well as for
those who speak a different language
 Explain that each face represents a person who may have no
pain, some pain, or as much pain as imaginable. Point to the
appropriate face and say the appropriate description. e.g. “This
face hurts just a little bit”

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Wong-Baker FACES Pain Rating
Scale
 Ask the patient to choose the face that best matches how she or
he feels or how much they hurt.

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Color Pain Rating Scale
 Ask the patient to point to the area on the scale that shows their
level of pain from white (no pain) to dark red (worst possible
pain).
 Obtain a number corresponding to the area where the patient
points.

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Severity Assessment
 McGill Pain Questionnaire
 Scale from 0 to 5
 From None to Severe Pain
 for children or adults who understand numerical
relationships.

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PAIN ASSESSMENT Tools

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5 Pain Treatment

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Goals of Pain Management Therapy
1) Decreased pain
2) Decreased healthcare utilization
o Decreased “shopping” for care
o Decreased emergency room visits
3) Improved functional status
o Increased ability to perform activities of daily living
o Return to employment

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Management
 Non-Pharamcological treatment
 Pharmacological treatment:
 Analgesics
 Adjuvants
 Others

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Non-pharmacological interventions
 Exercise
 Weight reduction
 Counseling
 Smoking cessation
 Massage ,Relaxation therapy
 Heat & cold applications

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Non-pharmacological interventions

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Analgesics
 Non-opioid
 e.g. aspirin,paracetamol
 Opioids
 e.g. codeine, morphine
 Adjuvant
 e.g. muscle relaxant, antidepressant, anti-epileptic

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Choosing the Appropriate Analgesic
 Match the severity of pain to the strength of the
analgesic i.e. strong analgesics for severe pain.
 The WHO has developed 3-step model to guide
analgesic choice depending on the severity of the
patient’s pain.

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WHO Pain Management Ladder
 Step I:
 NSAIDS ± adjuvants
 Step II:
 NSAID + Mild opioids ± adjuvant
 Step III:
 Strong opioids + NSAIDS ± adjuvants

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Analgesics(Non-opioids)
 There are three types of non-opioid analgesics:
i. Salicylates
ii. Non-Steroidal Anti-Inflammatory Drugs
iii.Acetaminophen

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Analgesics(Non-opioids)
 Used in full doses for the most part.
 All have a ceiling effect to their analgesia ( a
maximum dose past which no further analgesia can
be expected).
 COX-2 inhibitors may be associated with fewer
side-effects

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Analgesics(Non-opioids)
 Use cytoprotection with NSAIDs only in patients
who have symptoms suggestive of GI distress or
who are at high risk of ulcer formation. For
cytoprotection use sulcrafate or misoprostol.

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Analgesics(Weak Opioids)
 Useful drugs:
o Codeine & codeine combination products
o Oxycodone combination products.
 DO NOT USE:
o Dextropropoxyphene

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Analgesics(Strong Opioids)
 Useful drugs:
o Morphine , hydromorphone, fentanyl, oxycodone ,
methadone.
 DO NOT USE:
o Meperidine , anileridine , pentazocine

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Opioid Dosing
 Opioid analgesia is most effective when titrated to effect.
 Effective doses are highly variable between patients.
 “Standard” doses may be insufficient.
 When used properly for analgesia addiction occurs in less
than 1% of patients.

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Opioid Side Effects
 Constipation :
o need proactive laxative use
 Nausea/vomiting:
o consider treating with dopamine antagonists and/or
prokinetics (metoclopramide, domperidone,
prochlorperazine, haloperidol)
 Urinary retention

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Cont.
 Itch/rash
o worse in children; may need low-dose naloxone infusion. May
try antihistamines, however not great success
 Dry mouth
 Respiratory depression
o uncommon when titrated in response to symptom
 Neurotoxicity: delirium, myoclonus seizures.
 Drug interactions

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Adjuvant analgesics (coanalgesics)
 Are medications that when added to primary
analgesics, further improve pain control.
 may themselves also be primary analgesics (e.g.
tricyclic antidepressant medications for postherpetic
neuralgia).
 They can be added into the pain management plan at
any step in the WHO ladder.

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Adjuvants for Neuropathic Pain
 When pain is neuropathic there is good evidence for
treating with adjuvant medication rapidly.
 Always remember the potential of using radiotherapy,
chemotherapy and surgery as adjuvant modalities with
neuropathic pain but they should not replace drug adjuvants
completely.
 An adequate trial of 2-4 weeks at full dosage should be
tried for each drug

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Adjuvants for Neuropathic Pain
 Cyclic Antidepressants:
o Amitriptyline - desipramine - nortriptyline –maprotiline
 Anticonvulsants:
o carbamazepine - valproic acid - gabapentin
 Local Anesthetics:
o mexiletine - lidocaine

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Other modalities
 Nerve blocks, epidural blocks and ablative
neurosurgical procedures may be effective in pain
management.
 Such procedures may be associated with return of
pain after a number of months so that timing of
procedures may be important.

56. Thanks
for Coming