Essential Pain Management

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 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
 Introduction
Summary

• Pain is common.
• Pain is often poorly treated.
• We need a better system.
• RAT provides this system.
 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

2.5
 Assess
R
• How severe is the pain?
• What type of pain is it? A
• Are there other factors?
T

A2
 Assessment of
Severity
• 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
 R
Classification of
A
Pain
T

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5.1
 Classification of
Pain
R
Duration Acute

Chronic
A
Cause Cancer

Non – cancer T
Mechanisme Nociceptive

Neiropathic

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
• Cancer pain R
– Progressive
– May be A
mixture of
acute and
chronic T
• Non‐cancer
pain
– Many
5.7
different
causes
 Nociceptive Pain
• Obvious tissue injury or illness R
• Sometimes called physiological pain
• Protective function A
• Description
– Sharp and/or dull T
– Well localised

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 T
numbness
– Not well localised
 Physiology
R
• 4 steps:
– Periphery
A
– Spinal cord
– Brain
– Modulation T
Periphery
• Tissue injury R
• Release of
chemicals A
• Stimulation of pain
receptors
(nociceptors) T
• Signal travels in Aδ
or C nerve to
spinal cord.
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.
 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.
 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.
 Treat
• Non‐pharmacological treatments? R
• Pharmacological treatments?
A

T
 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
 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.
 R

9.4