Chronic pain management

Outline
What is pain? Definition of pain
Classification of pain
Differences between acute and chronic
pain
Principles of management of patient with
chronic non-cancer pain
Principles of management of patient with
cancer pain
What happens to a patient at a Pain Clinic?

What is Pain?
International Association for the Study of
Pain
Pain is "an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage.
Merskey,1964
International Association for
the Study of Pain (IASP)

What do you understand

about pain ?
From the definition of pain, we
understand that pain is .
Unpleasant
Emotions are important
The cause is not always visible

To patient ..
PAIN

is what the patient says.

HURTS

Classification of Pain

Classification of Pain
Not all pain is the same!
Three main questions:
1. How long has the patient had pain?
2. What is the cause?
3. What is the pain mechanism?

Classification of Pain
Duration

Cause
Mechanis
m

Acute
Chronic
Acute on chronic
Cancer
Non-cancer
Nociceptive (physiological)
Neuropathic (pathological)

Acute versus Chronic

Acute
Pain of recent onset and probable limited
duration

Chronic
Pain persisting beyond healing of injury
Often no identifiable cause
(Pain lasting for more than 3 months)

Cancer versus Non-Cancer

Cancer pain
Progressive
May be mixture of acute and chronic

Non-cancer pain
Many different causes
Acute or chronic

Nociceptive Pain
Obvious tissue injury or illness
Physiological pain
Description
Sharp dull
Well localised

Neuropathic Pain
Nervous system damage or abnormality
Pathological pain
Tissue injury may not be obvious
Description
Burning, shooting numbness, pins and needles,
allodynia
Not well localised

Differences between Nociceptive

and Neuropathic pain
T a b le :2 .3 :&D iffe re n c e s&b e tw e e n &N o c ic e p tiv e &p a in &a n d &N e u ro p a th ic &p a in &
&
&
&

N o c ic e p tiv e &p a in &

P h y sio lo gic a l&p a in &

N e u ro p a th ic &p a in &
P a th o lo gic a l&p a in &

C a u se !

O b v io u s !t is s u e !in ju r y !

N e r v e !in ju r y !o r !
C e n t r a l/ p e r ip h e r a l!n e r v o u s !
s y s t e m !a b n o r m a lit y !

F u n c t io n !

P r o t e c t iv e !f u n c t io n !

N o !d is c e r n a b le !b io lo g ic a l!
f u n c t io n !

D e s c r ip t io n !o f !p a in !

Sh arp !
D u ll!
T h r o b b in g !
W e ll!lo c a lis e d !

B u r n in g !
S h o o t in g !
S t a b b in g ,!la n c in a t in g !
P o o r ly !lo c a lis e d !

A g g r a v a t in g !/ !r e lie v in g !
fa cto r s!

A g g r a v a t e d !b y !m o v e m e n t !
R e lie v e d !b y !r e s t !

S p o n t a n e o u s !p a in !

O t h e r !s y m p t o m s !

N o n e !o r !r e la t e d !t o !u n d e r ly in g ! N u m b n e s s !
p a t h o lo g y !
P in s !a n d !n e e d le s !
A llo d y n ia !
D y s a e s t h e s ia s !

&
N e u ro p a t h ic &P a in &
&

Spectrum of Pain
ACUTE
PAIN

Healing

NO PAIN

Insidious onset

CHRONIC
PAIN

ACUTE
PAIN

post-surgical, post-trauma syndromes

cancer

CHRONIC
PAIN

5th Vital Sign: Doctors training module: Pain Physiology

Acute vs Chronic Pain

Acute Pain

Chronic Pain

Onset and
timing

Sudden onset, short duration.

Resolves/disappears when
tissues heal.

Onset may be insiduous.

Pain persists despite tissue
healing.

Signal

A warning sign of actual or

potential tissue damage

Not a warning signal of

damage : a false alarm

Severity

Severity is correlates with

amount of damage.

Severity not correlated with

damage.Good days and
Bad days.

CNS
involvement

CNS intact acute pain is a

symptom

CNS may be dysfunctional

chronic pain is a disease

Psychological
effects

Less, but unrelieved pain

anxiety & sleeplessness (which
improves when pain is relieved)

Often associated with

depression, anger, fear,
social withdrawal, etc

Common
causes /
examples

Surgery, fracture, burns,

myocardial infarct, labour and
childbirth, inflammatory
conditions e.g. abscess

Chronic headache, back

pain, chronic pelvic / abd
pain, cancer pain,
neuropathic pain PHN,
DPN, post stroke pain, etc

5th Vital Sign: Doctors training module: Pain Physiology

ASSESSMENT OF THE
CHRONIC PAIN PATIENT

How to assess pain:

P : Place or site of pain
Where does it hurt?
(record on a body chart)

A : Aggravating factors
What makes the pain worse?

I : Intensity
How bad is the pain?

N : Nature and neutralizing

factors
What does it feel like What makes
the pain better?

Other questions to ask about pain in patients

with chronic pain
Pattern of pain:

Is the pain always there (constant)? Or does the pain

come and go (intermittent or episodic pain)?

Associated symptoms:

Do you have the following symptoms in the painful area or

Numbness, tingling, allodynia (pain from a non painful

elsewhere?
stimulus), hyperalgesia (pain out of proportion to a painful
stimulus)

Other questions to ask about pain in patients

with chronic pain
Impact of pain on mood and function:

How does the pain affect your sleep? Your appetite? Your
mood? Your daily activities? Your relationships? Your work?

Past History:

Past medical/surgical history, past and current

medications.

Other information:

Patients understanding about his/her pain and its cause;

expectations about pain management.

Principles in the management of

chronic non-cancer pain
Use a multimodal approach
Non-drug techniques (e.g. exercise, relaxation, counselling,
acupuncture
Analgesic medications
Non opioids e.g. Paracetamol
Opioids e.g. Tramadol
Antineuropathic agents e.g. Amitriptline, Gabapentin

Nerve blocks and other interventions

Involve the patient as an active participant
Self-management techniques are very important
Management is targetted at achieving long-term benefit as
chronic pain is a disease which needs long term solutions
including life-style changes (similar to diabetes, heart
disease)

Practical tips on management of patients

with chronic non-cancer pain in the ward
First, you must recognise that the patient has
chronic pain i.e. pain for more than 3 months
No need for further investigations if patient is
admitted (or comes to Emergency dept) for
exacerbation (flare up) of the chronic pain.
Only investigate if patient has different type of pain
or has new symptoms e.g. loss of weight, vomiting,
etc

All patients with chronic pain should be

referred to the chronic pain clinic for full
assessment and long term management.

Practical tips on management of patients

with chronic non-cancer pain in the ward
In the ward or Emergency department
1. Avoid analgesic injections i.e. do not give IM or IV
Pethidine or Diclofenac.
2. Give regular oral analgesic eg oral tramadol 100
mg TDS or QID + Paracetamol 1 g QID
3. Refer to a chronic pain clinic
4. Refer to physiotherapy for assessment and an
exercise program that the patient can do at home
5. Discharge the patient as soon as the pain is under
control do not keep the patient in the ward for
long periods of time.

If a pain clinic is not

available:
Give the patient a follow up appointment at your
clinic (e.g. surgical, medical)
Emphasize to the patient that s/he should come for
regular follow-up and not just when s/he has flare
ups (severe pain), and that s/he has to learn how to
manage his/her pain (and that there is no cure)
When the patient comes for follow-up, focus not just
on the pain itself (as chronic pain will always be
present) but on function and mood, i.e. what the
patient is doing (back to work?), how is s/he feeling
and how is her/his relationship with his/her family
and friends.

What happens to a patient with

chronic pain at the Pain Clinic?
The patient has a thorough multidisciplinary assessment, which
includes
Medical assessment by a pain specialist
To make a diagnosis and decide whether any further investigations are
indicated,
Review of current treatment

Physical assessment by a physiotherapist

To assess for primary and secondary musculoskeletal effects of chronic
pain.

Psychological assessment by a clinical psychologist or

psychiatrist.
To assess the psychological impact of the pain, level of anxiety and
depression, how the patient copes with the pain, effect on
relationships, sleep, work, etc.

What happens to a patient with

chronic pain at the Pain Clinic?
After assessment, a management plan is made.
Management is multidisciplinary and multimodal, and
includes any or all of the following modalities:
Pharmacotherapy, using appropriate drugs
nerve blocks and other interventions,
active physiotherapy, including exercises and activities that
patients can do at home
psychological therapy, including relaxation training and other
pain management strategies

In the management of chronic pain, emphasis is on selfmanagement (what the patient can do for him/herself)
and achieving long-term changes (e.g. from exercise)
rather than short-term gains (e.g. from short acting
analgesic medications).

Management of patient with chronic

cancer pain
If a patient has cancer pain, s/he should be
assessed fully, like any other patient with pain
A diagnosis should be made and appropriate
investigations done (e.g. to determine
whether there are secondaries from the
primary tumour)
Refer to palliative care / pain service if
available
If not available, use the WHO analgesic ladder
to manage the patients pain

WHO Analgesic Ladder

From: Malaysian CPG on Management of Cancer Pain, 2010;

27 availability. Geneva: WHO; 1996
Adapted from World Health Organization. Cancer pain relief (Second Edition) with a guide to opioid

Summary
Pain can be classified as acute or chronic, cancer or noncancer and nociceptive or neuropathic
Acute and chronic pain are different
Acute pain is a symptom of tissue damage
Chronic pain is a disease of the nervous system

Acute and chronic pain need to be treated differently,

using non-drug as well as drug techniques.
For patients with chronic cancer or non-cancer pain,
many other factors (e.g. psychosocial) may be
important and need to be taken into consideration in the
management.
Self-management for long term benefit is essential in patients
with chronic pain