EPM Slides 2ed 082016 PDF

Essential Pain Management
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Introduction
1.1
Why EPM?
1.2
Why EPM?
• Pain is common.
• Pain is often poorly managed.
• We need a better system.
1.3
EPM is a system
For managing pain
For teaching others
1.4
A System?
Trauma Pain
Multiple causes Multiple causes
Team management Team management
ABC system No system
ATLS, PTC training ?
1.5
Overall EPM Aims
Better recognition
Better assessment
Better treatment
1.6
Workshop Objectives
You will be able to:
• Recognize pain
– Define pain
– List benefits of treating pain
• Assess pain
– Measure severity
– Classify types of pain
– Assess other factors
1.7
Workshop Objectives
• Treat pain
– List non‐pharmacological treatments
– List pharmacological treatments
• Devise an action plan to address local
barriers.
1.8
Workshop Plan
• Short, interactive lectures
• Discussions on barriers and solutions
• Case discussions
1.9
Untreated Pain
1.10
Untreated Pain
• Often hidden (not recognized)
• Causes a lot of suffering
• But … can often be treated simply and
cheaply
1.11
RAT System
• Recognize
• Assess
• Treat
1.12
Recognize
• Does the patient have pain?
• Do other people know the patient has pain?
R2
1.13
Assess
• How severe is the pain?
• What type of pain is it?
• Are there other factors?
A4
1.14
Treat
• What non‐pharmacological treatments
can I use?
• What pharmacological treatments can I
use?
A4
1.15
1.16
Introduction
Summary
• Pain is common.
• Pain is often poorly treated.
• We need a better system.
• RAT provides this system.
1.17
Recognize
Assess
Treat
R1
1.7
Recognize
R
• Do other people know the patient has pain? A
• The next lectures will cover: T
– The definition of pain
– The benefits of treating pain
R2
R
What is Pain? A
2.1
What is Pain?
Objectives
R
A
• Define pain
• Use this definition to recognize pain T
2.2
Group Discussion
R
• Think of a patient who has or had pain.
• How did he or she describe the pain? A
2.3
Does this person have pain?
R
2.4
What is Pain?
• International Association for the Study of R
Pain (IASP)
– Pain is ‘an unpleasant sensory and emotional A
experience associated with actual or potential
tissue damage, or described in terms of such
damage’. T
• Are there any other definitions?
2.5
What is Pain?
• Pain is unpleasant. R
• Emotions are important.
• The cause is not always visible. A
• 'Pain is what the patient says hurts.’ T
2.6
Does this person have pain?
R
2.7
R
2.8
What is Pain?
Summary
R
• Pain is an unpleasant sensory and emotional A
experience.
• Remember to ask! T
2.9
R
Why Should We Treat Pain? A
3.1
Why Should We Treat Pain?
Objectives
R
A
• List the benefits of treating pain:
– For the patient T
– For the family
– For society
3.2
Case Discussion 1
• Mrs T is a 33‐year‐old woman with uterine R
cervical cancer. The cancer has spread to
her spine and she has disabling pain. The A
surgeons do not have any other options to
treat her cancer. She is married with two
children, aged 11 and 8. T
• Why should we treat her pain?
3.3
Case Discussion 2
• Mr G is a 54‐year‐old man who has just had R
a laparotomy for bowel obstruction. You
see him on the surgical ward soon after the A
operation. He complains of severe pain.
• Why should we treat his pain?
T
3.4
Benefits of Treating Pain
• For the patient R
– Physical
• Better sleep, improved appetite A
• Fewer medical complications
(e.g. heart attack, pneumonia)
– Psychological T
• Reduced suffering
• Less depression, anxiety
3.5
Benefits of Treating Pain
• For the family R
– Improved function as part of the family
(e.g. as a father / mother) A
– Able to keep working
• For society T
– Reduced health costs
(e.g. shorter hospital stay)
– Able to contribute to the community
3.6
What are the benefits for this child?
R
3.7
Group Discussion
R
• Are there any reasons for NOT treating
pain? A
3.8
R
3.9
Why Should We Treat Pain?
Summary
R
• Treating pain is the ‘humane’ thing to do!
• Treating pain has many benefits: A
– For the patient
– For the family T
– For society
3.10
Recognize
Assess
Treat
A1
1.7
Assess
R
• What type of pain is it? A
T
A2
Assess
R
– What is the pain score? A
– How is the pain affecting the patient?
T
A3
Assess
R
• What is the pain type?
– Acute or chronic? A
– Cancer or non‐cancer?
– Nociceptive or neuropathic? T
A4
Assess
R
– Physical? A
– Psychological?
T
A5
Assess
R
• The next lectures will cover:
– Assessment of severity A
– Classification of pain
– Underlying physiology and pathology T
A6
R
Assessment of Severity A
4.1
Assessment of Severity
Objectives
R
A
• Understand the reasons for assessing
severity T
• Use different methods to assess severity
4.2
R
• Guides choice of treatment
• Measures response to treatment A
• ‘Pain is the 5th vital sign.’ T
– Measure and record severity
4.3
• What is the pain score? R
– At rest?
– With movement? A
• How is the pain affecting the patient?
– Can the patient move, cough? T
– Can the patient work?
4.4
Methods
• Verbal Rating Scale R
– Mild, moderate, severe
– 0 (no pain) to 10 (worst pain imaginable) A
• Visual
– Visual Analogue Scale (VAS)
– Faces Pain Scale (FPS) T
• Other
– Functional Activity Score (FAS)
– More specialised methods
4.5
Visual Analogue Scale
R
Ask the patient to show what his/her pain is
on a scale of 0 to 10. A
4.6
Faces Pain Scale
R
4.7
Functional Activity Score
• Is pain limiting function? R
• Steps
– Pain at rest (0 to 10) A
– Pain during activity (0 to 10), e.g. deep breathing,
getting out bed
• Score T
– A: No limitation
– B: Mild‐moderate limitation
– C: Severe limitation
4.8
R
4.9
Summary
R
• Assessment of severity guides treatment
and measures response. A
• Common methods include:
– Verbal Rating Scale T
– Visual Analogue Scale
– Faces Pain Scale
4.10
R
Classification of Pain A
5.1
Classification of Pain
Objectives
R
A
• Classify types of pain
• Give examples of types of pain T
• Understand that treatment depends on the
pain type
5.2
• Not all pain is the same! R
• Three main questions:
A
1. How long has the patient had pain?
2. What is the cause? T
3. What is the pain mechanism?
5.3
R
Duration Acute
Chronic A
Cause Cancer
Non‐cancer
T
Mechanism Nociceptive (physiological)
Neuropathic (pathological)
5.4
Acute versus Chronic
• Acute R
– Pain of recent onset and probable limited
duration A
• Chronic
– Pain lasting for more than 3 months
T
– Pain lasting after normal healing
– Sometimes no identifiable cause
5.5
Cancer versus Non‐Cancer
R
Need one of sick patient / cancer
5.6
Cancer versus Non‐Cancer
• Cancer pain R
– Progressive
– May be mixture of acute and chronic A
• Non‐cancer pain
– Many different causes T
– Acute or chronic
Can you give examples of non‐cancer pain?
5.7
Nociceptive Pain
• Obvious tissue injury or illness R
• Sometimes called physiological pain
• Protective function A
• Description
– Sharp and/or dull T
– Well localised
Can you give examples?
5.8
Neuropathic Pain
• Caused by a lesion or disease of the sensory R
nervous system
• Tissue injury may not be obvious
A
• Does not have a protective function
• Description
– Burning, shooting, pins and needles, or numbness T
– Not well localised
Can you give examples?
5.9
R
Examples of Pain Types A
5.10
Acute Non‐Cancer Pain
• Examples R
– Fracture, appendicitis
• Symptom of tissue injury or illness A
• Usually nociceptive
• Occasionally neuropathic (e.g. sciatica) T
5.11
How would you classify low back pain?
R
5.12
Chronic Non‐Cancer Pain
• Examples R
– Chronic back pain, arthritis
• Cause may not be obvious A
• Complex, may be mixed nociceptive and
neuropathic T
• Different pharmacological treatments
may be needed
5.13
Cancer Pain
• Examples R
– Uterine cervical cancer, breast cancer
– Metastases in bone A
• Features of acute and chronic pain
– May be acute on chronic T
• Often mixed nociceptive and neuropathic
pain
• Usually gets worse over time if untreated
5.14
R
5.15
Summary
R
• Deciding on the type of pain is important.
– Acute / chronic A
– Cancer / non‐cancer
– Nociceptive / neuropathic T
• Treatment depends on the pain type.
5.16
R
Pain Physiology and Pathology A
6.1
Pain Physiology and Pathology
Objectives
R
A
• Understand normal pain physiology
– Nociceptive pathway T
– Factors affecting pain perception
• Understand the basis of neuropathic pain
(pathology)
6.2
Why is pain physiology important?
R
• Many factors affect how we feel pain.
– Psychological factors are very important. A
• Different treatments work on different parts T
of the pathway.
– More than one treatment is usually needed.
6.3
Nociception and Pain
• Nociception R
– How pain signals get from the site of injury to
the brain. A
• Pain
– How we perceive or feel pain.
T
• Nociception is not the same as pain!
6.4
R
Is this man feeling pain?
6.5
Nociception is not the same as pain!
Nociception
R
Beliefs Other illnesses
e.g. religion e.g. cancer
A
Psychol. factors
Personality
e.g. anger, anxiety
Cultural issues Social factors

T
e.g. expectations e.g. family, work
Pain
What the patient says hurts.
What must be treated.
6.6 Modified from Analgesic Expert Group. Therapeutic Guidelines 2007
Physiology
R
• 4 steps:
– Periphery
A
– Spinal cord
– Brain
– Modulation T
• We will look at each
step.
6.7
Periphery
• Tissue injury R
• Release of
chemicals A
• Stimulation of pain
receptors
(nociceptors) T
• Signal travels in Aδ
or C nerve to
spinal cord.
6.8
Spinal Cord
• Dorsal horn is the R
first relay station.
• Aδ or C nerve
synapses A
(connects) with
second order
nerve. T
• Second order
nerve travels up
opposite side of
spinal cord.
6.9
Brain
• Thalamus is the
second relay station. R
• Connections to
many parts of the
brain. A
– Cortex
– Limbic system
– Brainstem T
• Pain perception
occurs in the brain.
6.10
Modulation
R
• Descending
pathway from A
brain to dorsal
horn.
• Usually inhibits T
pain signals from
the periphery.
6.11
Neuropathic Pain
• Pathological pain R
• Abnormality of nociceptive pathway
– Peripheral nerves A
– Spinal cord or brain
• Needs different pharmacological T
treatments
How do patients describe their pain?
6.12
Neuropathic Pain ‐ Mechanisms
• Abnormal nerve tissue, e.g. amputation R
neuroma
• Abnormal firing of pain nerves A
• Changes in chemical signalling in the dorsal
horn
• Abnormal nerve connections in the dorsal T
horn
• Loss of normal inhibitory function
6.13
R
6.14
Pain Physiology and Pathology
Summary
R
• Nociception is not the same as pain.
• Physical and psychological factors affect A
how we feel pain.
• Different treatments work on different T
parts of the nociceptive pathway.
• Neuropathic pain needs different
pharmacological treatments.
6.15
Recognize
Assess
Treat
T1
1.7
Treat
• Non‐pharmacological treatments? R
• Pharmacological treatments?
A
• The next lectures will cover:
– Non‐pharmacological and pharmacological T
treatments
– Pharmacology of common pain medications
T2
R
Pain Treatment Overview A
7.1
Pain Treatment Overview
Objectives
R
A
• Describe the non‐pharmacological and
pharmacological treatments that are T
available
• Classify pain treatments
• Understand the role of placebo treatment
7.2
Group Discussion
R
• What non‐pharmacological treatments are
available? A
• What pharmacological treatments are
available? T
7.3
Non‐Pharmacological Treatments
• Physical R
– Rest, ice, compression, elevation
– Surgery A
– Acupuncture, massage, physiotherapy
• Psychological T
– Explanation
– Reassurance
– Counselling
7.4
Pharmacological Treatments
• Simple analgesics R
– Paracetamol (acetaminophen)
– Anti‐inflammatory medicines, e.g. ibuprofen A
• Opioids
– Mild, e.g. codeine, tramadol T
– Strong, e.g. morphine, pethidine, oxycodone
7.5
Pharmacological Treatments
• Other analgesics R
– Tricyclic antidepressants, e.g. amitriptyline
– Anticonvulsants, e.g. carbamazepine, A
gabapentin
– Local anaesthetics
T
– Others, e.g. ketamine, clonidine
7.6
Treatments ‐ Periphery
R
• Non‐pharm
treatments
A
– Rest, ice,
compression,
elevation
T
• Anti‐inflammatory
medicines
• Local anaesthetics
7.7
Treatments ‐ Spinal Cord
R
• Non‐pharm
treatments
A
– Acupuncture,
massage
• Local anaesthetics T
• Opioids
• Ketamine
7.8
Treatments ‐ Brain
• Non‐pharm
R
treatments
– Psychological A
• Pharmacological
treatments
– Paracetamol T
– Opioids
– Amitriptyline
7.9
Group Discussion
R
• What is a placebo treatment?
• Is it helpful or unhelpful? A
7.10
Placebo Treatment
R
• Psychological factors are important.
• If a placebo treatment works, this does not A
mean that the patient did not have pain or
was telling lies! T
7.11
R
7.12
Pain Treatment Overview
Summary
R
• Both non‐pharmacological and
pharmacological treatments are important. A
• Different treatments work on different
parts of the nociceptive pathway. T
• Pain medications can be classified into
simple analgesics, opioids and other
analgesics.
7.13
R
Pain Medications A
8.1
Pain Medications
Objectives
R
A
• Outline broad principles of
pharmacological treatment T
• Summarise the major advantages and
disadvantages of important medications
• Address concerns about opioid addiction
8.2
Broad Principles
• This lecture: R
– Gives a broad overview of pharmacological
treatment in common situations A
– Gives examples of medications
T
• For more detail, including doses:
– Case discussions
– EPM manual and EPM app
8.3
Treatment of Cancer Pain
WHO Ladder*
Step 3 R
Severe pain
Step 2 Use strong
Moderate pain opioid A
e.g. morphine
Use mild opioid
Continue simple
Step 1 e.g. codeine,
analgesics
Mild pain tramadol T
Continue simple
Use simple analgesics
analgesics
Add other medications for neuropathic pain
e.g. amitriptyline, gabapentin
8.4 *Modified
WHO Ladder
• Developed for cancer pain R
• Emphasises oral treatment
• Treats nociceptive pain A
• May need other medications for
neuropathic pain T
• Don’t forget non‐pharmacological
treatments!
8.5
Treatment of Acute Nociceptive Pain
Reverse WHO Ladder
R
Step 3
Severe pain
Use strong Step 2 A
opioid Moderate pain
e.g. morphine
Use mild opioid
Also use simple
e.g. codeine, Step 1
T
analgesics
tramadol Mild pain
Continue simple
analgesics Continue simple
analgesics
8.6
Reverse WHO Ladder
• Mainly useful for severe acute nociceptive R
pain
– Trauma pain A
– Post‐operative pain
• Start at the top and ‘step down the T
ladder’ as the pain improves.
8.7
Chronic, Non‐Cancer Pain
• Non‐pharmacological treatments very R
important
• May need treatment for neuropathic pain A
– Antidepressants, e.g. amitriptyline
– Anticonvulsants, e.g. gabapentin T
• Opioids are usually not helpful and may
cause harm.
8.8
R
Examples of Pain Medications A
8.9
Paracetamol (Acetaminophen)
• Indications R
– Mild nociceptive pain
– Moderate to severe nociceptive pain A
(with other medications)
• Advantages
– Cheap, safe T
– PO, PR, IV
• Disadvantages
– Liver damage in overdose
8.10
Ibuprofen
• Indications R
– Mild, moderate or severe nociceptive pain
• Advantages A
– Cheap
– Usually safe if given short‐term T
• Disadvantages
– Gastric and renal side effects
– Interferes with blood clotting
8.11
Tramadol
• Indications R
– Nociceptive and neuropathic pain
• Advantages A
– Safe
– Useful for different pain types
– Can be used with morphine T
• Disadvantages
– Nausea and vomiting
– Confusion
8.12
Morphine 1
• Indications R
– Moderate to severe, acute, nociceptive pain
– Cancer pain A
• Advantages
– Very effective T
– Cheap
– Usually safe
– PO, IV, IM, SC
8.13
Morphine 2
• Disadvantages R
– Nausea and vomiting
– Respiratory depression in high dose A
– Constipation
– Misunderstandings about addiction
T
– Legal controls
8.14
Morphine Dosing
• Oral dose is 2‐3 times IV / IM / SC dose. R
Why is this?
A
• Tolerance
– Increased dose needed over time T
– Very high doses may be needed in cancer
treatment
8.15
Amitriptyline
• Indication R
– Neuropathic pain
• Advantages
– Cheap A
– Safe in low dose
– Also treats depression, poor sleep
• Disadvantages T
– Harmful in overdose
– Dry mouth, drowsiness
– Urinary retention
8.16
Gabapentin
• Indication R
– Neuropathic pain
• Advantages A
– Safe and effective
• Disadvantages T
– Drowsiness
– Dose needs to be increased slowly
8.17
Group Discussion
R
• What is addiction?
• How common is opioid addiction in patients A
with pain?
• Would this stop you giving opioids to a T
patient who has pain?
8.18
Opioids and Addiction
• Addiction – Three C’s R
– Craving
– Loss of control A
– Negative consequences (harm)
• Addiction is very rare in acute pain and T
cancer pain.
• Addiction may occur if strong opioids are
used to treat chronic non‐cancer pain.
8.19
Group Discussion
R
• Name 3‐5 other pain medications used to
treat different types of pain. A
• What are their:
– Indications? T
– Advantages?
– Disadvantages?
8.20
Medication Effectiveness
Acute Acute Acute Chronic Chronic
noci noci neuro non‐ cancer
mild severe cancer
Paracetamol +++ ++ + + +
NSAIMs ++ ++ + +/‐ +/‐
Codeine ++ + ‐ ‐ +/‐
Tramadol ++ ++ ++ + +
Morphine ‐ +++ ++ ‐‐ +++
TCAs ‐ ‐ ++ ++ ++
Anticonvulsants ‐ ‐ ++ + +
8.21
R
8.22
Pain Medications
Summary
R
• Pain can be treated with relatively cheap
and safe drugs. A
• Morphine is very effective for cancer pain
and acute severe nociceptive pain. T
• In general, strong opioids should be avoided
in chronic non‐cancer pain.
8.23
R
Pain Management Barriers A
9.1
Pain Management Barriers
Objectives
R
A
• Summarise local pain management barriers
• Develop a plan to address local barriers T
9.2
Group Discussion
• Pain is often poorly managed. What are R
some of the reasons for this?
– Patient factors A
– Medications
– Health workers
T
– System issues
• What are the main barriers where you
work?
9.3
R
9.4
Pain Management Barriers
Summary
R
• Pain is often poorly managed.
• Barriers include lack of knowledge, health A
worker attitudes and lack of medications.
• You can help to address these barriers T
where you work!
9.5
R
Using the RAT System A
10.1
Using the RAT System
Objectives
R
A
• Summarise the RAT system
• Apply this system to different types of pain T
• Understand the importance of
reassessment
10.2
R
10.3
R
• Recognize
A
• Assess
• Treat T
10.4
• Recognize R
• Assess
– Severity? A
– Type?
– Other factors? T
• Treat
– Non‐pharmacological treatments
– Pharmacological treatments
10.5
Recognize
R
– Ask A
– Look
• Do other people know the patient has pain? T
– Other health workers
– Patient’s family
10.6
Assess
R
– Measure at rest A
– Measure with movement
T
10.7
Assess
R
• What type of pain is it?
– Acute or chronic? A
– Cancer or non‐cancer?
– Nociceptive or neuropathic? T
10.8
Assess
R
– Physical factors A
• Underlying illness
• Other illnesses
T
– Psychological and social factors
10.9
Treat
R
• Non‐Pharmacological Treatments
– For both nociceptive and neuropathic pain A
– Physical
(e.g. rest, ice, elevation, physiotherapy,
massage) T
– Psychological
(e.g. reassurance, explanation, counselling)
10.10
Treat
R
• Pharmacological Treatments –
Nociceptive Pain A
– Consider paracetamol, NSAIMs, tramadol,
codeine, morphine T
– Use combinations
(e.g. paracetamol + NSAIM + opioid)
– Use IV morphine for acute, severe pain
10.11
Treat
R
• Pharmacological Treatments –
Neuropathic Pain A
– Consider using tramadol, tricyclic
antidepressant (e.g. amitriptyline) or T
anticonvulsant (e.g. gabapentin)
10.12
Reassess
R
• Repeat RAT
A
• Is your treatment working?
• Are other treatments needed?
T
10.13
Example 1
R
• A 32‐year‐old man caught his right hand in
A
machinery at work. He presents with a
compound fracture of his hand.
• How would you manage his pain using T
RAT?
10.14
Example 2
R
• A 55‐year‐old woman presents with a large
A
breast tumour with spread to her spine.
She has severe pain.
• How would you manage her pain using T
RAT?
10.15
Example 3
R
• A 51‐year‐old man has a 2‐year history of
A
lower back pain which sometimes radiates
down his right leg. He fell recently and is
now having problems walking. T
• How would you manage his pain using
RAT?
10.16
R
10.17
Summary
R
• Recognize
• Assess
– Severity?
A
– Type?
– Other factors?
• Treat T
– Non‐pharmacological treatments
– Pharmacological treatments
• Reassess
10.18
www.essentialpainmanagement.org
epm@anzca.edu.au
facebook.com/essentialpainmanagement

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Essential Pain Management

Team management Team management

Cultural issues Social factors

NSAIMs ++ ++ + +/‐ +/‐

Morphine ‐ +++ ++ ‐‐ +++

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