PAIN MANAGEMENT

Pain is a more terrible lord of mankind than death itself.

Albert Schweitzer

PAIN
An unpleasant sensory and emotional stimulus associated with actual or potential tissue damage or described in terms of such damage.
(International Association for the study of Pain, 1979)

Pain is whatever the experiencing person says it is, existing whenever he/she says it does.
(McCaffery 1968

The word "pain" comes from the Latin: poena meaning punishment, a fine, a penalty. The two most common forms of pain are headache and back pain.

 Pain is the most common reason for which individuals seek medical attention

 Despite it causing suffering, pain is a critical component of the body's defense system. It instructs the central nervous system to initiate motor neurons response in order to minimize detected physical harm. Lack of ability to experience pain, as in the rare condition Congenital insensitivity to pain or Congenital Analgesia, can cause various health problems.

Objectives
Causes of pain Why is it necessary to treat pain?? Effects of pain Types of pain Pain physiology

 Why treat pain?

Tissue damage has the potential to elicit mechanisms that can create disabling, refractory, chronic situations that may prolong and even outlast the period of healing. Hedderich & Ness, 1999

Causes of pain
Inflammatory causes due to any infection or infestations. Hypoxia due to poor blood supply like MI,peripheral vascular disease. Trauma Obstruction like intestinal obstruction. Compression over nerve roots like in intervertebral disc collapse Advanced malignancies etc

Consequences of Unrelieved Pain

Acute Pain
Increased sympathetic activity Splinting, shallow breathing Increased catabolic demands Peripheral/ central sensitization

GI effects

Anxiety and fear

Myocardial O2 consumption

GI motility

Atelectasis, hypoxemia, hypercarbia

Poor wound healing/muscle breakdown

Sleeplessness, helplessness

Available drugs

Myocardial ischemia

Delayed recovery

Pneumonia

Weakness and impaired rehabilitation

Psychological Chronic pain

Courtesy of Sunil J Panchal, MD

Substances released
The substances released from the traumatized tissue are: prostaglandins bradykinin serotonin substance P histamine Prostaglandins E2 sensitize nerve endings to the action of bradykinin,histamin and other chemical mediators

Anatomy and Physiology of Nociceptive Pain

4 Basic Processes

Transductionnociceptors,the free nerve endings when exposed to noxious stimuli like mechanical (incision or tumor growth), thermal (burn), or chemical (toxic substance) stimuli, tissue damage occurs. Substances are released by the damaged tissue which facilitates the movement of pain impulse to the spinal cord.

Transduction (cont.)
Sufficient amounts of noxious stimulation cause the cell membrane of the neurons to become permeable to sodium ions, allowing the ions to rush into the cell and creating a temporary positive charge. Then potassium transfers out of the cell, thus changing the charge back to a negative one. With this depolariztion and repolarization, the noxious stimuli is converted to an impulse. This impulse takes just milliseconds to occur.

Process #3Perception of Pain

The end result of the neural activity of pain transmission It is believed pain perception occurs in the cortical structuresbehavioral strategies and therapy can be applied to reduce pain. Brain can accommodate a limited number of signalsdistraction, imagery, relaxation signals may get through the gate, leaving limited signals (such as pain) to be transmitted to the higher structures.

Process #4Modulation of Pain

Changing or inhibiting pain impulses in the descending tract (brain spinal cord) Descending fibers also release substances such as norepinephrine and serotonin (referred to as endogenous opioids or endorphins) which have the capability of inhibiting the transmission of noxious stimuli. Helps explain wide variations of pain among people. Cancer pain responds to antidepressants which interfere with the reuptake of serotonin and norepinephrine which increases their availability to inhibit noxious stimuli.

Pain pathway and modulation1

Ascending nociceptive pathways Interpretation in cerebral cortex: pain Descending inhibitory controls / Diffuse noxious inhibitory controls Activation of serotoninergic and noradrenergic pathways

Stimulation of nociceptors (A and C fibers) / Release of neurotransmitters and neuromodulators (i.e. PG)

Release of serotonin, noradrenalin and enkephalins at spinal level

Injury
1. Adapted from: Bonica JJ. Postoperative pain. In Bonica JJ, ed. The management of pain. Philadelphia: Lea and Febiger;1990:461-80.

NERVE PATHWAY OF PAIN

Modes of action of analgesics1,2,3,4

Paracetamol Inhibition of central Cox-3 (?) (Inhibition of PG synthesis)

Opioids Activation of opioid receptors

Paracetamol Interaction with serotoninergic descending inhibitory pathway

NSAIDs / Coxibs Inhibition of peripheral and central Cox-1 / Cox-2 (Inhibition of PG synthesis)
1. DAmours RH et al. JOSPT 1996;24(4):227-36. 2. Piguet V et al. Eur J Clin Pharmacol 1998;53:321-4. 3. Pini LA et al. JPET 1997;280(2):934-40. 4. Chandrasekharan NV et al. PNAS 2002;99(21):13926-31.

Opiod analgesics
Analgesic properties are mediated by opiod receptors.These are G protein coupled receptors which are associated with ion channels and ultimateley impede neuronal firing and transmitter release. Opiods relieve pain by 1.Raising pain threshold at the spinal cord level and more importantly by 2.Altering the brains perception of pain.
Note: Morphine causes respiratory depression.

 Pain modulators like endorphins and opiod peptides in brain and spinal cord inhibit the release of substance P. Local anesthetic agents like lidocaine,bupevacaine are charged at phsiological pH and these ionized form interacts with the protein receptor of Na+ channel to inhibit its function and thus inhibit neuronal firing.

Management of Pain
After clinical assesement of pain including physical examination and proper investigations 1 Correction of underlying cause like removal of renal stone or cholecystectomy for gallstones 2 Surgical removal of tumour 3 Hormone therapy 4 Chemotherapy for malignancies 5 Radiotherapy 6 Mental relaxation 7 Education of the team involved in pain management and the patients themselves etc

Non-Drug Strategies
Exercise
PT, OT, stretching, strengthening general conditioning

Chiropracty Acupuncture TENS LLLT Alternative therapies

relaxation, imagery herbals

Physical methods
ice, heat, massage

Cognitivebehavioral therapy

Analgesic Drugs
Acetaminophen NSAIDs
Non-selective COX inhibitors Selective COX-2 inhibitors

Opioids Others
Antidepressants Anticonvulsants Substance P inhibitors NMDA inhibitors Others

NSAIDS
Aspirin Diclofenac Indomethacin Nimesulide Ketorolac Meloxicam Ketoprofen etc

Cox 2 inhibitors
Celecoxib Etoricoxib Rofecoxib
Other Analgesics Acetaminophen

Opiod Analgesics
Strong agonists Morphine Suphentanyl Fentanyl Methadone Moderate agonists Codeine Oxycodeine Propoxyphene Partial agonists Nalbuphine Pentazocine Buprenorphine Other analgesics - Tramadol.

First Step: Evaluate the Pain

Look for underlying causes Assess the pain as an entity in itself
Onset, Character, and Magnitude on scale of 0 to10 Constant or Intermittent? What makes it better or worse? (e.g. rest, medication) Detailed history of prior evaluations and treatments How does it affect physical function and work? How does it affect social and mental functioning?

MISCONCEPTIONS ABOUT PAIN

Myth: If they dont complain, they dont have pain Fact: There are many reasons patients may be reluctant to complain, despite pain that significantly affects their functional status and mood.

REASONS PATIENTS MAY NOT REPORT PAIN

Fear of diagnostic tests Fear of medications Fear meaning of pain Perceive physicians and nurses too busy Complaining may affect quality of care Believe nothing can or will be done

Treatment methods :
1-Systemic opiods. 2-Patient-controlled analgesia. 3-Regional anesthetic techniques .
. a : Intraspinal analgesia. b :Patient-controlled epidural analgesia. c :Combined spinal-epidural technique.

4-intraarticular analgesia. 5-Nonopioid analgesics. 6-Cryoanalgesia. 7-T.E.N.S. 8-Psychologic and other methods.

PCA devices :
Consists of a microprocessor-controlled pump triggered by depressing a button . When pump is triggered ,a preset amount of drug is delivered into the patients I.V. line. Lockout interval :A specific period setted in the pump to prevent administration of an additional bolus.

Side effects of PCA:

Nausea ,Vomiting ,Itching. Treated by changing opioid or using drugs that provide symptomatic relief. A pre printed set of standard orders can facilitate a uniform standard of care.

Transcutaneous electrical nerve stimulation(T.E.N.S.)

Uses both for chronic pain and acute perioperative pain. Advantages: absence of opioids side effects (resp. depression, sedation, nausea and vomiting, urinary retention) It is simple, noninvasive and free of toxicity.

Some More Invasive Therapies

Trigger Point Injections Joint Injections Regional Nerve Blocks Epidural Injection Various Surgeries-sympathectomy for vascular diseases,cordotomy for severve pain in case of advanced tumours,anterior cingulectomy for intractable phantom pain

Traditional Approach to Cancer Pain

Preventive Multimodal Analgesia

Significant improvement in
Pain reduction Opioid use Opioid-related AEs Recovery or day ward length of stay Unplanned admission to the hospital

Reuben et al. Acute Pain. 2004;6:87-93.

Pain: Clinical Types

Nociceptive pain
Transient pain in response to noxious stimuli

Inflammatory pain
Spontaneous pain and hypersensitivity to pain in response to tissue damage and inflammation

Neuropathic pain
Spontaneous pain and hypersensitivity to pain in association with damage to or a lesion of the nervous system

Is responsive to NSAIDs, coxibs, Nociceptive Pain paracetamol and opiates

Noxious Peripheral Stimuli
Heat Cold Intense Neuron Mechanical Force Chemical Irritants Spinal Cord
Nociceptor Sensory

Pain-Autonomic Response
- Withdrawal Reflex

Brain

Woolf. Ann Intern Med. 2004;140:441-451.

Inflammatory Pain
Macrophage Mast Cell Neutrophil Granulocyte

Is responsive to NSAIDs,coxibs, paracetamol, and opiates Pain Inflammation Spontaneous

Pain Hypersensitivity -Allodynia -Hyperalgesia

Brain

Nociceptor Sensory Neuron

Tissue Damage
Spinal Cord

Woolf. Ann Intern Med. 2004;140:441-451.

Neuropathic Pain
Spontaneous Pain Pain Hypersensitivity

May respond to local anaesthetic anticonvulsants antidepressants Peripheral Nerve

Damage

Brain
Stroke

Less responsive to opioids

Spinal Cord Injury

No response to NSAIDs, coxibs, or paracetamol .

Woolf. Ann Intern Med. 2004;140:441-451

Postoperative pain is nociceptive

Perception

Modulation Is responsive to NSAIDs,coxibs, paracetamol and opiates

Transmission

Transduction
Reuben et al. J Bone Joint Surg. 2000;82:1754-1766.

TYPES OF PAIN
Pain can be classified as acute or chronic. Acute pain is defined as short-term but extreme pain that comes on quickly but last only for a brief period of time. Acute pain is the body's warning of present damage to tissue or disease. It is often fast and sharp followed by aching pain. Acute pain is centralized in one area before becoming somewhat spread out. This type of pain responds well to medications.

 Chronic pain was originally defined as pain that has lasted 6 months or longer. It is now defined as pain that persists longer than the normal course of time associated with a particular type of injury. This constant or intermittent pain has often outlived its purpose, as it does not help the body to prevent injury. It is often more difficult to treat than acute pain.

CUTANEOUS PAIN
Cutaneous pain is caused by injury to the skin or superficial tissues. Cutaneous nociceptors terminate just below the skin, and due to the high concentration of nerve endings, produce a well-defined, localized pain of short duration. Examples of injuries that produce cutaneous pain include paper cuts, minor cuts,minor (first degree) burns and lacerations.

SOMATIC PAIN
Somatic pain originates from ligaments, tendons, bones, blood vessels, and even nerves themselves. It is detected with somatic nociceptors. The scarcity of pain receptors in these areas produces a dull, poorly-localised pain of longer duration than cutaneous pain; examples include sprains and broken bones.

VISCERAL PAIN
Visceral pain originates from body's viscera, or organs. Visceral nociceptors are located within body organs and internal cavities. Visceral pain is extremely difficult to localize, and several injuries to visceral tissue exhibit "referred" pain, where the sensation is localized to an area completely unrelated to the site of injury. The theory that visceral and somatic pain receptors converge and form synapses on the same spinal cord pain-transmitting neurons is called "Ruch's Hypothesis".

PHANTOM LIMB PAIN

Phantom limb pain is the sensation of pain from a limb that has been lost or from which a person no longer receives physical signals. It is an experience almost universally reported by amputees and quadriplegics.

NEUROPATHIC PAIN
Neuropathic pain, or "neuralgia", can occur as a result of injury or disease to the nerve tissue itself. This can disrupt the ability of the sensory nerves to transmit correct information to the thalamus, and hence the brain interprets painful stimuli even though there is no obvious or known physiologic cause for the pain.

 Chronic pain is essentially caused by the bombardment of the central nervous system (CNS) with nociceptive impulses, which causes changes in the neural response. The pain subsequently provokes changes in the behavior of the patient, and the development of fear-avoidance strategies. As a result, the patient may also become physically atrophied and deconditioned. However, it is important to remember that chronic pain is multifactorial, with the underlying biological changes affecting physical and psychosocial factors.

CAUSES

INVESTIGATIONS
Full Physical Examination Full Blood Count or Complete Blood Count X-Ray (General Radiology and Fluoroscopy CT Scan or CAT scan Fine Needle Aspiration Biopsy (FNA) MRI (Magnetic Resonance Imaging) PET Scan (Positron Emission Tomography) Ultrasound (Ultrasound Scanning or Sonography and Doppler)

T R E A T M E N T

Analgesia Appendicectomy Cognitive-Behavioural Therapy (CBT) Corticosteroids for pain relief Introduction to Neurostimulation Medical Acupuncture Nerve blocks (Regional anaesthesia) Opioids for analgesia Paediatric pain management Spinal Cord Stimulation Spinal Cord Stimulation Devices Sympathectomy and Sympathetic Nerve Block Trigger Point Injection of Local Anaesthetic

PAIN MANAGEMENT
Pain management (also called pain medicine) is the discipline concerned with the relief of pain. Pain has been described as, "An unpleasant sensory and emotional experience associated with either actual or potential tissue damage. It is a very personal and individual experience defined as whatever the patient says it is, and it exists wherever he or she says it does."

 Acute pain, such as occurs with trauma, often has a reversible cause and may require only transient measures and correction of the underlying problem. Chronic pain often results from conditions that are difficult to diagnose and treat, and that may take a long time to reverse.

 Pain management generally benefits from a multidisciplinary approach that includes Pharmacologic measures (analgesics such as narcotics or NSAIDs and pain modifiers such as tricyclic antidepressants or anticonvulsants) Non-pharmacologic measures (such as interventional procedures, physical therapy and physical exercise, application of ice and/or heat), Psychological measures (such as biofeedback and cognitive therapy).

CHRONIC PAIN MANAGEMENT

Chronic pain is often more difficult to treat than acute pain. Expert physician care is generally necessary to treat any pain that has become chronic and usually involves a multi-disciplinary team which may include a combination of physiotherapists, psychologists, counselors, and specialists, such as cancer or palliative care nurses for cancer or physicians who specialize in spine medicine for back pain.

 Depression is common for patients with chronic back pain, and it is important to treat both the pain and depression. In managing chronic pain and in choosing which painkillers to use, beneficial analgesic effects must be balanced against any suffered drug side-effects if overall quality of life is to be improved. For example, with opioids, patients may need to adjust the dosage to reach a compromise between actual pain-killing effect and an acceptable level of nausea or constipation.

OPIOID ANALGESIA
Also called a narcotic or painkiller are used for prolonged periods drug tolerance, chemical dependency and (rarely) psychological addiction may occur. Chemical dependency is somewhat common among opioid users; however, psychological addiction rarely occurs. Apparent drug tolerance to the pain-relieving effects of opioids may occur. This may be confused with progression of the underlying disease in cancer patients, back pain patients and other chronic pain sufferers, rather than an actual decrease in efficacy of the drug.

 Acute Pain Drugs Opioids Epidural anesthesia Drug infusion

Pain management

 First Level Simple analgesics (Aspirin,paracetamol,NSAIDS,Tricyclic Antidepressants)

Chronic pain due to malignancy

Second Level Intermediate opioids codeine,tramadol,dextropropoxyphene

 Third level Strong opioids like oral morphine,intravenous morphine,subcutaneous diamorphine,epidural diamorphine; neurolytics whenever there is limited life expectancy.other method includes subcostal phenol injection for rib secondaries, celiac plexus block using alcohol,intrathecal hyperbaric phenol,percutaneous anterolateral cordotomy,pituitary ablation,hormone ablation,palliative radiotherapy,steroids and flecainide therapy.