PAIN MANAGEMENT

KEYWORDS Analgesia / Pain / Pain assessment / Patient information

Provenance and Peer review: Commissioned by the Editor; Peer reviewed.

Principles of acute
pain management
by Lorraine McMain
Correspondence address: WB Loan Pain Centre, Gardner Robb Building, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB. Email: lorraine.mcmain@belfasttrust.hscni.net

Acute pain is a predominant feature of the perioperative experience for the majority of
patients. This paper aims to describe the adverse effects of poorly controlled acute,
postoperative pain and provides an overview of the organisational aspects involved in pain
management in hospitals. Following this there will be an examination of the role information
giving has in improving the patient’s perioperative experience. Pharmacological and non-
pharmacological interventions to prevent or reduce pain will also be described and because
of its importance in setting the standard for logical prescribing in pain, the Analgesic Ladder,
devised by the World Health Organisation (WHO 1986) will be given special consideration.
Finally, the importance of pain assessment and re-assessment will be discussed.

Introduction  Reduced blood flow to viscera and Haemostasis

Failure to treat acute pain can have
adverse physical and psychological
consequences for the patient.
Furthermore, inadequate treatment of
acute pain can result in progression to a
persistent or chronic pain state (Macrae
2001). This is undesirable for the patient,
from a bio-psycho-social perspective and
also from an economic viewpoint.
Physiological effects
Adverse physiological effects result from
the combination of tissue injury and pain.
Broadly speaking, physiological responses
include increased catabolism,
immunosuppression and prolonged
maintenance of the sympathetic response
to surgery (Kumar & Smith 2003, ANZCA
2005). The effects of this have been sub-
classified into systemic responses by
Kehlet (1997) and may manifest
themselves as follows:
Cardiovascular effects
 Increased heart rate.
 Increased blood pressure.
 Increased stroke volume.
 Increased myocardial oxygen
demands, reduced myocardial oxygen
supply and possible myocardial
ischaemia.
skin causing delayed wound healing
(Bessey 1995, Kehlet 1997).  Immobility
 Increased blood viscosity
Respiratory effects  Hypercoagulability and risk of deep
vein thrombosis (Kehlet 1997,
 Stimulation of respiration causing Liu et al 1995)
initial hypocapnia and respiratory
alkalosis.
Psychological effects of pain
 Diaphragmatic splinting and
hypoventilation, atelectasis, hypoxia Pain is also an emotional phenomenon
and ensuing hypercapnia. (Merskey & Bogduk 1994). Acute pain,
 Development of chest infection though unpleasant, tends to be viewed as
(Bessey 1995, Kehlet 1997, having a useful purpose, in that it prompts
Brodner et al 1998). us to seek medical help. Generally, patients
try to make sense of their pain and will, to a
greater or lesser extent, expect to suffer
Endocrine effects acute pain because they have experienced
injury or need to have surgery.
 Catabolic and anabolic changes.
 Decrease in insulin production. If pain is poorly controlled and becomes
 Reduction in testosterone level. persistent following surgery, the patient no
longer deems it to be useful. The patient’s
 Fluid retention (Bessey 1995, bio-psycho-social state, prior to a painful
Kehlet & Nielsen 1998).
event, can positively or negatively contribute
to the pain experience (Horn & Munafò
Metabolic effects 1997) but the experience of inadequately
controlled pain is most likely to cause
 Raised blood sugar levels adverse psychological effects for the
(Kehlet & Nielsen 1998). patient. According to Eccleston (2001)
psychological changes tend to occur more
Gastro-intestinal effects insidiously, are often less apparent and the
reasons for these changes are multi-
 Delayed gastric emptying factorial.
 Nausea
Psychological and behavioural outcomes on
 Reduced gastro-intestinal motility and how the pain experience is viewed can be
ileus (Kehlet 1997). influenced by gender, age, cultural or

472 November 2008 / Volume 18 / Issue 11 / ISSN 1467-1026


religious beliefs; what feelings have been
internalised, regarding the significance of
their injury, surgery and the reason for their
pain (Skevington1995). Environmental
factors, such as noise levels and inability to
sleep may also have an impact on the
patient’s psyche during hospital stay. Some
patterns of cognition and behaviour are
listed below:
 Altered perception of the pain
experience.
 Attention and hyper-vigilance.
 Fear.
 Fear avoidance behaviour.
 Worry and catastrophising.
 Anxiety.
 Anger.
 Sleep deprivation.
 Low mood.
 Self-denigration.
 Depression (Eccleston 2001,
Horn & Munafò 1997).
All of this can have implications for
response to future pain and form the
basis for long-term behavioural changes.
Persistent pain after surgery
A clear relationship between having surgery
and suffering from persistent pain has been
identified (Perkins & Kehlet 2000, Macrae
2001). Pathophysiological processes that
occur after surgery can cause a chronic
pain condition to develop. This has been
demonstrated by Crombie et al (1998) who
undertook an audit of 5,130 patients
attending 10 chronic pain clinics and found
that surgery had contributed to the referral
in 22.5% of cases. Trauma was the reason
in 18.7% of patients. Thus, it is proposed
that early and appropriate analgesic
intervention may reduce the incidence of
chronic pain referrals (ANZCA 2005).
Organisational aspects of
acute pain management
The report of the working party entitled
Pain after Surgery (RCS, RCA 1990) was
November 2008 / Volume 18 / Issue 11 / ISSN 1467-1026
Acute pain, though unpleasant, tends to be
viewed as having a useful purpose
the impetus for development of structured
pain service delivery across the UK.
Guidelines, published by ANZCA (2005),
recognise that the type of pain service
needed will ultimately depend upon the
setting and complexity of caseload. Most
NHS hospital trusts, with theatre services,
have implemented the recommendations
of the Royal College Report and we now
have the availability of further, joint
guidelines on provision of UK pain
services (RCA & British Pain Society,
2003).
The consensus is that management of
simple analgesic regimens should remain
within the domain of those practitioners
who are delivering care at the coalface.
Expert clinical assistance from the pain
service, education and provision of
guidelines on best practice should be
readily available, when called upon. More
complex pain management techniques,
such as epidural analgesia, should be
routinely referred to and then
systematically reviewed by the pain team
(RCA & British Pain Society 2003).
The aims of a pain service are to:
 Reduce the risk of poor postoperative
outcome, previously described.
 Provide clinical support and expert
advice on how best to manage
patients experiencing acute pain (both
surgical and non-surgical) while in
hospital.
 Manage patients with complex pain.
 Organise services so that level of care
and monitoring is appropriate for both
the clinical condition of the patient
and the analgesic modalities involved.
 Provide training for those staff involved
in management of postoperative care.
 Ensure that patients have
understanding of techniques and
drugs used to treat pain in order to
allow them to make informed choices.
 Audit outcomes and adverse effects to
treatment.
 Undertake rigorous study on aspects
of pain management thus expanding
the evidence base for treatment (RCA
& British Pain Society, 2003).
PAIN MANAGEMENT
The RCA and British Pain Society (2003)
have also clearly defined the main
structures and resources required for
maintenance of adequate acute pain
service provision as follows:
 Specialist personnel, such as a
consultant anaesthetist who has
sessions devoted to pain
management, a specialist nurse to co-
ordinate day-to-day management of the
service and a pharmacist.
 Equipment dedicated for sole use
within the pain service.
 Drugs safely stored and pre-prepared
for administration.
 A department or base for the team.
Patient information giving
and pain
Timmins (2007) states that information
giving or teaching is needed to support
the patient and family. Information has
become a pre-requisite for those persons
making decisions on whether or not to
undergo surgery and to be able to
understand the therapies associated with
postoperative pain management. Provision
of information is an essential component
of self-efficacy, self-direction and effective
self-care. Accurate information and
understanding of information giving should
improve patient participation with care
and reduce dissatisfaction.
While it is accepted that preoperative
preparation is beneficial (Egbert et al
1964), coping strategies and behaviour
among patients vary considerably and
exert influences on the usefulness of
providing detailed preoperative
information. Delivery of preoperative
information should therefore be tailored
accordingly (Klafta & Roisin 1996,
Bergman et al 2001, Murtagh & Thorns
2008). For instance a person may
understand that morphine is used for
relief of pain but may wish to find out
more about the side-effects and risks of
addiction before agreeing to have patient
controlled analgesia (PCA).
It is important to provide information in a
structured manner and this means ➜
473
PAIN MANAGEMENT

Principles of acute pain management

Continued

identifying who should deliver it. Key
relationships for the patient during the
perioperative period will include all
members of the multi-disciplinary team
(MDT) such as medical staff, ward staff,
operating department staff and
physiotherapists. Those best placed to
provide information will be the
practitioners who have had an opportunity
to develop a relationship with the patient.
This can be difficult, for many reasons
including organisational barriers (Timmins,
2008).
Thus eliciting patient preference in clinical
practice is of paramount importance
(Murtagh 2008). Bergman et al (2001)
found that extensive, detailed oral and
written information had no effect on
patients’ perioperative stress indicators
(such as plasma cortisol), anxiety levels or
well-being when having cardiac surgery but
was critical of how routine preoperative
information is supplied. Chumbley et al
(2004) found that written preoperative
information about PCA had no effect on
pain relief, anxieties about addiction,
safety and knowledge about side-effects.
Nevertheless, patients felt better informed
and less confused after receiving it,
compared with preoperative interview
alone.
making choices. Turnbull (2003) found
that patients favour learning from other
patients. Berry et al (2006) examined how
patients prioritised their information
requirements for drug administration in
nurse prescribing and found them to be:
 possible side effects
 what the drug does and how it works
 likelihood of efficacy
 outcomes if patient declines to accept
the medication
 how medications interact.
Mumford (1997) has been critical of
nurses’ attempts to produce
understandable information material.
Having assessed readability of patient
leaflets with relevant formulae she
suggests that nurses fail to interpret
medical terminology into everyday
language. Chumbley (2002) sought to
elicit the information patients wanted,
regarding PCA and found that patients’
contribution in the production of an
Figure 1 World Health Organisation (WHO) analgesic ladder
information leaflet led to major change in
leaflet design. This, in turn, produced a
clearer, more attractive and informative
leaflet, which was more satisfactory to
patients.
To further assist in the production of
information leaflets the Department of
Health (DH 2003) has identified key
elements to preparation of information for
those contemplating production of
information leaflets. These are:
 planning
 writing
 consultation
 printing and distribution
 clarity
 evidence base
 patient participation.
WHO Analgesic Ladder
The WHO analgesic ladder (1996),
originally devised to provide guidance in

What can also be difficult to ascertain is

which method to choose for
administration of patient information:
where and when to offer it. Moult et al STEP 3 Opioid for moderate to
reduce dose or move down one step
Signs of toxicity or severe side effects,

(2004) contend that only 20% of verbal severe pain.

information is remembered. Macfarlane et Moderate to
Plus non-opioid.
al (2002) found that 50% more severe pain
With/without
information is retained, when reinforced by adjuvant analgesic.
Pain persisting, move up one step

written information. As patients have

diverse characteristics, such as
differences in gender, culture, age, literacy, STEP 2 Opioid for mild to moderate pain.
Mild to
level of disability and preference these Plus non-opioid.
moderate pain
must be taken into account. Human With/without adjuvant analgesic
diversity, in all its forms will mean that an
analysis of individual patient group needs,
or indeed an individual patient will inform
practice but it may present difficulties for STEP 1 Non-opioid.
development of a generic template on Mild pain
With/without adjuvant analgesic.
which to base the information to be
delivered (Timmins 2007).
Several authors have looked at the type of
information patients prefer to have, when

474 November 2008 / Volume 18 / Issue 11 / ISSN 1467-1026


Figure 2 Ladder of decreasing pain intensity (Bandolier 2003)
MAJOR
SURGERY
INTENSITY OF PAIN
TIME – PAIN DECREASES
the management of cancer pain, is the
framework most often applied in logical
prescription and titration of analgesia in
acute and chronic pain states. Step 1
recommends the use of non-opioid
analgesia for mild pain; Step 2 advocates
the use of ‘weak opioids’, with or without
non-opioids for moderate pain; Step 3 is
comprised of ‘strong opioids’, with or
without non-opioids, for severe pain. If
needed adjuvant drugs can be used at any
step (see Figure 1).
As can be seen in Figure 1, the three-
steps recommend that analgesia is
prescribed and administered according to
the intensity of pain. The ladder refers to
specific medicine classes, not specific
medicines, which permits clinicians to use
the ladder without reference to regulations
and limitations used in their respective
countries.
Some commentators on the ladder have
expressed concern in relation to the
misleading interpretation of the concept of
the three-step ladder, arguing that a less
November 2008 / Volume 18 / Issue 11 / ISSN 1467-1026
Local anaesthesia is not included in the ladder
but is often the mainstay of pain relief
MINOR
SURGERY
experienced clinician may diligently follow
the recommendation of progressive
placement of one foot above the other,
one rung at a time, with no shortcuts. This
approach will succeed in treating gradual,
progressive pain but does not address
pain that is severe to begin with.
Correspondents on behalf of the IASP
(Merskey & Bogduk 2005) therefore
emphasise the need to be logical and
choose analgesia according to the severity
of the pain; more analogous to taking an
‘analgesic elevator’ to the appropriate
floor than climbing a ladder. A variation of
the ladder model has been adapted to
suit a scenario for acute postoperative
pain (Bandolier 2003) (see Figure 2).
This model is devised on the premise that
patients having major surgery will
experience severe pain and those having
minor procedures will experience pain of
more moderate intensity. However
limitations to its application exist and it is
important that inter-patient variability is
taken into account. Pain is a very
PAIN MANAGEMENT
subjective experience and there may also
be factors which contribute to why a
patient having a minor procedure requires
larger quantities of opioid than another
patient having the same procedure (for
example a cancer patient already
established on strong opioids). Also
neither model describes techniques or
routes used to administer strong opioids
in patients who are likely to have a ‘nil by
mouth’ status. In addition, local
anaesthesia is not included in the ladder
but is often the mainstay of pain relief in
the early postoperative phase for many
patients having major surgery. Merskey
and Bogduk (2005) also recommend that
additional options to pharmacological
treatment are considered. This may
reduce the risk of patients suffering from
inadequate levels of pain control and
unacceptable side-effects.
Interventions in acute pain
Causes of acute pain can be multi-
factorial and for this reason require an
imaginative, multi-modal and bio-psycho-
social approach to management. Further
management strategies and their sub-
groups are described by Hawthorn and
Redmond (1998) and the evidence for use
of many techniques cited in the ANZCA
guidelines (2005). Choice of treatment
will depend on the cause of pain and the
status of the patient. A taxonomic
approach to treatment classifies
management into two main groups, with
several sub-groups (see Table 1).
The scope of this paper means that only a
brief explanation of each sub-category can
be set out. Routes of administration are
described but not discussed.
Pharmacological
management
Systemic analgesics
Designed to relieve pain through direct
action, these analgesics can be
administered alone or in combination with
other drugs and techniques: ➜
475
PAIN MANAGEMENT
Principles of acute pain management
Continued
Table 1 Adapted from ANZCA guidelines (2005)
Pharmacological
Systemic
Regional/local
Condition-specific
Interventional
 Non-opioids such as paracetamol;
nefopam also sits within this
classification.
 Non-Steroidal Anti-Inflammatory Drugs
(NSAIDs) such as diclofenac and COX
II selective inhibitors, such as
parecoxib.
 Opioids, of which those frequently
used, include morphine, codeine,
tramadol, fentanyl, oxycodone,
dihydrocodeine, buprenorphine,
methadone and diamorphine.
 Adjuvants to analgesia often have a
primary indication, other than pain but
assist in the management of the
patient’s pain. They are usually
administered in combination with at
least one or more of the primary,
systemic analgesics. The usefulness
of the drug will depend on the
presence of other symptoms
associated with the pain. It is also
important to explain to the patient that
the primary indication for the drug is
not the reason for its use in their
particular case. Examples of such
drugs include the anti-convulsant
gabapentin, which is used to treat
neuropathic pain. Another group of
drugs are anti-depressants, like
amitriptyline, also used for
neuropathic pain. Other adjuvants
include ketamine, antihistamines,
corticosteroids, anti-spasmodics,
bisphosphonates and calcitonin. It is
important to note that specialist
knowledge is required when
considering whether or not to add
medications, such as ketamine, to the
patient’s analgesic regimen.
476
Non-pharmacological
Neurostimulation
Acupuncture
Cognitive-behavioural strategies
Other complementary therapies
 Entonox, a mixture of 50% oxygen and
50% nitrous oxide is a gas which has
analgesic properties and can be
useful for short, painful procedures.
Its poor solubility in blood allows rapid
onset of analgesia.
Routes of administration can be varied
and imaginative but the oral or gastro-
intestinal route is best, if available.
Examples of common routes of
administration for some within this group
of drugs include intravenous,
intramuscular, subcutaneous,
transdermal, rectal, inhalation and
transmucosal.
Regional and local analgesics
Local anaesthetics bind to sodium
channels and block the action potentials
for nerve conduction in every type of
nerve fibre (depending on the
concentration, route and rate of
administration of the medicine). They
can produce an absence of sensation in
the part of the body to which they are
applied, without impairment of central
control of vital functions or loss of
consciousness (Kumar & Smith 2003).
Clinical application of local anaesthesia
can be topical, ophthalmic, wound
infiltration, intra-articular, peripheral nerve,
spinal or epidural routes of administration
(Hawthorn & Redmond 1998).
Condition-specific drugs
Required to treat pain caused by
conditions such as acute angina.
Glyceryltrinitrate is an example of a typical
treatment for this.
November 2008 / Volume 18 / Issue 11 / ISSN 1467-1026
Interventional techniques
Acute pain caused by tissue damage or
distension will require final resolution in
the form of surgery or decompression.
Non-pharmacological
management
Neurostimulation
Transcutaneous electrical nerve
stimulation (TENS) has traditionally been
used in chronic pain settings but has also
been found to be beneficial for some
acute pain situations. Efficacy will be
dependent on the settings used. It is
recommended that patients must feel a
strong, but comfortable level of
stimulation. The idea is to use TENS to
contribute towards dynamic pain relief,
reduce consumption of opioids and
incidence of opioid-induced side-effects.
(Bjordal et al 2003, Proctor cited in ANZCA
2005.)
Acupuncture
This is another treatment more typically
used in chronic pain management.
However, there is limited but good quality
evidence to suggest that acupuncture may
be useful for pain in childbirth, treatment
of headache and dental pain (Melchart et
al 2001, Smith et al 2003, Ernst & Pittler
cited in ANZCA 2005). Electro-acupuncture
was also found to reduce postoperative
opioid requirements and opioid-induced
side effects (Lin et al 2002, Kotani et al
cited in ANZCA 2005.)
Cognitive-behavioural strategies (CBT)
CBT begins with two assumptions (Turk &
Fernandez cited in Horn & Munafò 1997).
First, thoughts, feelings, mood, motivation
and behaviour are reciprocally inter-
related. Second, patients are constantly
engaged in adaptive behaviour and making
judgements about their capacity to deal
with life’s problems. The threat of pain or
illness invokes physiological, psychological
and behavioural responses and CBT is a

therapeutic method of taking all of this
into account. CBT focuses on appraisal,
interpretation and expectation as well as
physiological and environmental
influences (Turk & Rudy cited in Horn &
Munafò 1997). CBT programmes are
collaborative endeavours between the
patient and the therapist. A programme of
intervention facilitates a sense of
personal self-control. Elements to CBT
include reconceptualisation of the pain,
cognitive restructuring, problem-solving,
relaxation, imagery and distraction (Horn
& Munafò 1997).
Other complementary and alternative
therapies (CAMs)
Defined as every available approach to
healing that does not fall within the realm
of conventional medicine in a Western,
industrialised society. Types of CAMs
include:
 Herbal medicine
 Traditional Chinese medicine
 Homeopathy
 Use of vitamins and minerals.
CAMs in management of acute pain is an
area where more evidence needs to be
collected (ANZCA, 2005).
Pain assessment
One of the recommendations of the
Working Party Report on Pain after Surgery
(1990) was that patients should have
their pain systematically assessed and
recorded (the idea being to improve the
levels of pain experienced by patients in
British hospitals). Therefore, one of the
functions of the Pain Team has been to
educate and reinforce to practitioners the
need to regularly assess and document
levels of pain and effectiveness of pain
relief (RCA & British Pain Society, 2003).
Assessment of acute pain refers to the
comprehensive, clinical process of
describing pain and its effect on patient
function in sufficient detail to achieve:
November 2008 / Volume 18 / Issue 11 / ISSN 1467-1026
Pain measurement requires the practitioner to
use a particular type of pain assessment tool
 Assistance in diagnosis and extent of
injury or disease.
 Selection of appropriate therapy.
 Evaluation of response to therapy
(Hobbs & Hodgkinson 2003).
Pain measurement requires the
practitioner to use a particular type of
pain assessment tool (Brown 2008). With
this tool the aim is to ascribe magnitude
and dimensions to a multi-dimensional
and subjective phenomenon, so most
measures are obtained by a self-report
method. The result is that a plethora of
tools have been developed for this
purpose. Practical and logistical factors
which influence the choice of best tool for
the job will include:
 Validation
 How easy it is to administer to the
patient
 The time it takes to administer to the
patient (Hawthorn & Redmond 1998,
Hobbs & Hodgkinson 2003).
Further factors which affect outcome,
when assessing pain, will include:
 How cognizant practitioners are on
how it should be applied.
 The ability of the assessor, particularly
in the case of children, older or
cognitively impaired patients, to
differentiate pain from distress.
 The subjectivity of the assessor
undertaking the measurement.
 The scope allowed or delay
encountered before the practitioner
can act on their findings (Wong &
Baker 1988, Hawthorn & Redmond
1998, British Pain Society 2007).
There are many factors, such as the
presence of severe cognitive impairment,
communication difficulties or language
and cultural barriers, which affect the
ability of even the most experienced and
patient assessor to effectively assess
pain. Older people with severe cognitive
impairment can find it difficult to articulate
their pain (British Pain Society 2007).
Paediatric pain assessment is a challenge
PAIN MANAGEMENT
because the group is so heterogeneous.
In the field of neonatal and childrens
nursing there is a requirement to assess
the pain of infants and children at
different stages of physical development.
Eloise Carr (2007) has described barriers
to patients reporting pain and barriers
that affect how receptive we are not only
to what patients report but also to non-
verbal cues. Carr (2007) states that there
can be obstacles to patients reporting
pain, even when asked about it, due to
worries about being unpopular,
assumption that they are in the hands of
the professional who has authority, fear of
injections and belief that the pain is not
harmful and is to be expected.
Patients’ self-report can also be
influenced by mood, loss of sleep and
medication effects (Hobbs & Hodgkinson
2003).
It has been postulated that pain intensity
should be recorded as the 5th vital sign
(Joint Commission on the Accreditation of
Healthcare Organizations (JCAHO) in full
first 2001, cited in ANZCA 2005).
Frequency of observation should depend
on the intensity of the pain, the type of
therapy used to treat it and the need to
evaluate that therapy. Dynamic pain
should be assessed, particularly the
patient’s ability to cough and to move the
affected body part. Pain at rest is also
relevant as this can give an indication
about how well a patient will be able to
sleep.
Conclusion
This paper has discussed why having
organised pain services can improve the
acute, postoperative pain experience for
patients. Also included was an
examination of the contribution
information-giving makes. Pharmacological
and non-pharmacological interventions to
prevent or reduce pain were described and
advice on the use of the Analgesic Ladder
provided. Finally, the importance of pain
assessment and re-assessment was
discussed.

477
PAIN MANAGEMENT
Principles of acute pain management
Continued
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About the author
Lorraine McMain
RGN, BSc(Hons), MSc
Chronic Pain Nurse,
Belfast City Hospital,
Belfast Health and Social
Care Trust
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