Pain management

DR. QURRAT-UL-AIN
KALEEM
(RESIDENT SURGERY)
Contents

 Introduction
 Classification
 Effects
 Pain assessment
 Treatment
 Pain management in Cancer pts
“Pain is an unpleasant sensory and emotional experience associated with actual
and potential tissue damage”

pain is experienced by 66% of patients suffering from terminal illness

1) Acute

2) Chronic
*Chronic Primary Pain
*Chronic Secondary pain
ACUTE PAIN

Injury, trauma, spasm or disease to skin, muscle, somatic structures or

viscera

Usually associated with autonomic response as well (tachycardia,

blood pressure, diaphoresis, pallor).
Chronic pain

1- Chronic primary

Pain persists beyond the precipitating injury

pain is linked with the condition itself e.g Fibromyalgia
2- Chronic secondary pain

 Has characteristics of chronic pain as well as symptoms

of acute pain (breakthrough pain)
 Has a definable cause, e.g. tumor recurrence
Effects of pain
Sympathetic responses
 Pallor
 Increased blood pressure
 Increased pulse
 Increased respiration
 Skeletal muscle tension
 Diaphoresis
Parasympathetic responses
 Decreased blood pressure
 Decreased pulse
 Nausea & vomiting
 Weakness
 Pallor
 Loss of consciousness
Comprehensive Pain Assessment

 Detailed History

 Intensity

 Location

 Duration

 Alleviating factors

 Meds tried
Management

 Needs multimodal and multidisciplinary approach

 1-Non Pharmacological Approach

-physiotherapy –exercise -CBT –Heat and Cold Therapy

 2- Pharmacological Approach
-Paracetamol –NSAIDs -TCAs
WHO Analgesia Ladder
Other modalities

 Nerve blocks, epidural blocks and ablative neurosurgical

procedures may be effective in pain management.
 Such procedures may be associated with return of pain
after a number of months so that timing of procedures
may be important.
 NICE Guidelines for Palliative Care of Adults

 Communication

 Concerns of Patients
 Addiction
 Tolerance
 Side Effects

 Provide info about opioids and their Safe Storage

 Offer patients frequent review of pain control

 Type of Opioid Examples

Morphine
Natural Opioids
Codeine

Oxycodone

Semi-Synthetic Opioids Hydromorphone

Hydrocodone

Fentanyl

Tramadol
Synthetic Opioids
Meperidine

Buprenorphine
 Starting Strong Opioids - Titrating the Dose

 Start with 20-30 mg/day of sustained release oral morphine for background pain and 5mg

SOS for breakthrough pain

 Dose should be adjusted until a good balance exist between acceptable pain control and side

effects

 Patients should be frequently reviewed particularly in titration phase

 Breakthrough Pain

 Sudden episodic more intense spikes of pain

 Offer 5mg of oral immediate release morphine for the first line rescue medication of

breakthrough pain

 1/6th of total dose of opioid for breakthrough pain as per SIGN guidelines
 First Line Maintenance Treatment
 Offer oral sustained release morphine as first line maintenance treatment to patients with

advanced & progressive disease who require strong opioid

 Transdermal patch and subcutaneous formulations shouldn’t be used as first line maintenance

treatment to patients in whom oral opioids are suitable

 Pain Management of Cancer Patient

 Non-Pharmacological Approaches:
 Interventional Procedures. Interventional procedures like nerve blocks, epidural injections, or neurolytic
blocks can provide targeted pain relief
 Physical Therapy. Physical therapy can help patients maintain mobility and function, reducing pain
associated with immobility
 Psychosocial Support. Psychological support, counseling, and relaxation techniques can help patients
cope with pain and improve their overall well-being-
 Tumor Related Causes of Cancer Pain
Causes of Cancer Pain Description
Tumor Growth Pain from tumor pressing on nearby tissues, nerves, or organs

Nerve Compression or Invasion Neuropathic pain due to tumor compressing or invading adjacent nerves

Deep, aching pain from cancer spreading to the bones. Worsens with movement or weight-
Bone Metastases
bearing

Visceral Pain Pain originating from internal organs, described as deep, dull, or cramping

Inflammatory Processes Pain due to cancer-induced inflammation, such as abdominal pain in pancreatic cancer

Compression of Blood Vessels Pain resulting from tumor compressing blood vessels, causing decreased blood flow

Chemical Mediators Pain triggered by chemical mediators released by tumors

 Treatment Related Causes of Cancer Pain
Causes of Cancer Pain Description
Pain can result from chemotherapy side effects, such as oral pain (mucositis) or peripheral
Chemotherapy
neuropathy

Pain from radiation therapy side effects, including skin irritation, tissue inflammation, and
Radiation Therapy
localized pain

Surgical Procedures Post-surgical pain following major procedures to remove tumors or organs

Procedural Pain Pain resulting from various medical procedures, such as biopsies or central line placements

Chemotherapy-Induced
Pain and neuropathy in the extremities due to specific chemotherapy drugs
Peripheral Neuropathy (CIPN)

Radiation-Induced Oral Oral pain resulting from radiation therapy to the head and neck, causing mucous membrane
Mucositis inflammation

Ischemic Pain from Thrombosis Pain from thrombosis (blood clots) caused by certain cancer treatments
Thank you