Pain management

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Definition

Pain management encompasses pharmacological, nonpharmacological, and other approaches to prevent, reduce, or stop pain sensations.

Description

Before considering pain management, a review of pain definitions and mechanisms may be useful. Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. PNS includes all nerves throughout the body except the brain and spinal cord.

A pain message is transmitted to the CNS by special PNS nerve cells called nociceptors. Nociceptors are distributed throughout the body and respond to different stimuli depending on their location. For example, nociceptors that extend from the skin are stimulated by sensations such as pressure, temperature, and chemical changes.

When a nociceptor is stimulated, neurotransmitters are released within the cell. Neurotransmitters are chemicals found within the nervous system that facilitate nerve cell communication. The nociceptor transmits its signal to nerve cells within the spinal cord, which conveys the pain message to the thalamus, a specific region in the brain.

Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural pain killers, called endorphins, that are meant to derail further pain messages from the same source. However, these natural pain killers may not adequately dampen a continuing pain message. Also, depending on how the brain has processed the pain information, certain hormones, such as prostaglandins, may be released. These hormones enhance the pain message and play a role in immune system responses to injury, such as inflammation. Certain neurotransmitters, especially substance P and calcitonin generelated peptide, actively enhance the pain message at the injury site and within the spinal cord.

Pain is generally divided into two categories: acute and chronic. Nociceptive pain, or the pain that is transmitted by nociceptors, is typically called acute pain. This kind of pain is associated with injury, headaches, disease, and many other conditions. It usually resolves once the condition that precipitated it is resolved.

Following some disorders, pain does not resolve. Even after healing or a cure has been achieved, the brain continues to perceive pain. In this situation, the pain may be considered chronic. The time limit used to define chronic pain typically ranges from three to six months, although some healthcare professionals prefer a more flexible definition, and consider chronic pain as pain that endures beyond a normal healing time. The pain associated with cancer, persistent and degenerative conditions, and neuropathy, or nerve damage, is included in the chronic category. Also, unremitting pain that lacks an identifiable physical cause, such as the majority of cases of low back pain, may be considered chronic. The underlying biochemistry of chronic pain appears to be different from regular nociceptive pain.

It has been hypothesized that uninterrupted and unrelenting pain can induce changes in the spinal cord.

In the past, intractable pain has been treated by severing a nerve's connection to the CNS. However, the lack of any sensory information being relayed by that nerve can cause pain transmission in the spinal cord to go into overdrive, as evidenced by the phantom limb pain experienced by amputees. Evidence is accumulating that unrelenting pain or the complete lack of nerve signals increases the number of pain receptors in the spinal cord. Nerve cells in the spinal cord may also begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Immune chemicals, primarily cytokines, may play a prominent role in such changes.

Considering the different causes and types of pain, as well as its nature and intensity, management can require an interdisciplinary approach. The elements of this approach include treating the underlying cause of pain, pharmacological and nonpharmacological therapies, and some invasive (surgical) procedures.

Treating the cause of pain underpins the idea of managing it. Injuries are repaired, diseases are diagnosed, and certain encounters with pain can be anticipated and treated prophylactically (by prevention). However, there are no guarantees of immediate relief from pain. Recovery can be impeded by pain and quality of life can be damaged. Therefore, pharmacological and other therapies have developed over time to address these aspects of disease and injury.

PHARMACOLOGICAL OPTIONS. Pain-relieving drugs, otherwise called analgesics, include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, narcotics, antidepressants, anticonvulsants, and others. NSAIDs and acetaminophen are available as over-thecounter and prescription medications, and are frequently the initial pharmacological treatment for pain. These drugs can also be used as adjuncts to the other drug therapies, which might require a doctor's prescription.

NSAIDs include aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters, such as prostaglandins. Acetaminophen is also effective against pain, but its ability to reduce inflammation is limited.

NSAIDs and acetaminophen are effective for most forms of acute (sharp, but of a short course) pain, but moderate and severe pain may require stronger medication. Narcotics handle intense pain effectively, and are used for cancer pain and acute pain that does not respond to NSAIDs and acetaminophen. Narcotics are classified as either opiates or opioids, and are available only with a doctor's prescription. Opiates include morphine and codeine, which are derived from opium, a substance naturally found in some poppy species. Opioids are synthetic drugs based on the structure of opium. This drug class includes drugs such as oxycodon, methadone, and meperidine (Demerol).

Narcotics may be ineffective against some forms of chronic pain, especially since changes in the spinal cord may alter the usual pain signaling pathways. Furthermore, narcotics are usually not recommended for long-term use because the body develops a tolerance to narcotics, reducing their effectiveness over time. In such situations, pain can be managed with antidepressants and anticonvulsants, which are also only available with a doctor's prescription.

Although antidepressant drugs were developed to treat depression, it has been discovered that they are also effective in combating chronic headaches, cancer pain, and pain associated with nerve damage. Antidepressants that have been shown to have analgesic (pain reducing) properties include amitriptyline (Elavil), trazodone (Desyrel), and imipramine (Tofranil). Anticonvulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) and carbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.

Other prescription drugs are used to treat specific types of pain or specific pain syndromes. For example, corticosteroids are very effective against pain caused by inflammation and swelling, and sumatriptan (Imitrex) was developed to treat migraine headaches.

Drug administration depends on the drug type and the required dose. Some drugs are not absorbed very well from the stomach and must be injected or administered intravenously. Injections and intravenous administration may also be used when high doses are needed or if an individual is nauseous. Following surgery and other medical procedures, patients may have the option of controlling the pain medication themselves. By pressing a button, they can release a set dose of medication into an intravenous solution. This procedure has also been employed in other situations requiring pain management. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug.

NONPHARMACOLOGICAL OPTIONS. Pain treatment options that do not use drugs are often used as adjuncts to, rather than replacements for, drug therapy. One of the benefits of non-drug therapies is that an individual can take a more active stance against pain. Relaxation techniques, such as yoga and meditation, are used to decrease muscle tension and reduce stress. Tension and stress can also be reduced through biofeedback,in which an individual consciously attempts to modify skin temperature, muscle tension, blood pressure, and heart rate.

Participating in normal activities and exercising can also help control pain levels. Through physical therapy, an individual learns beneficial exercises for reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body's natural pain killers.

Acupuncture involves the insertion of small needles into the skin at key points. Acupressure uses these same key points, but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged are very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupting pain signals and inducing release of endorphins. To be effective, use of TENS should be medically supervised.

INVASIVE PROCEDURES. There are three types of invasive procedures that may be used to manage or treat pain: anatomic, augmentative, and ablative. These procedures involve surgery, and certain guidelines should be followed before carrying out a procedure with permanent effects. First, the cause of the pain must be clearly identified. Next, surgery should be done only if noninvasive procedures are ineffective. Third, any psychological issues should be addressed. Finally, there should be a reasonable expectation of success.

Anatomic procedures involve correcting the injury or removing the cause of pain. Relatively common anatomic procedures are decompression surgeries, such as repairing a herniated disk in the lower back or relieving the nerve compression related to carpal tunnel syndrome. Another anatomic procedure is neurolysis, also called a nerve block, which involves destroying a portion of a peripheral nerve.

Augmentative procedures include electrical stimulation or direct application of drugs to the nerves that are transmitting the pain signals. Electrical stimulation works on the same principle as TENS. In this procedure, instead of applying the current across the skin, electrodes are implanted to stimulate peripheral nerves or nerves in the spinal cord. Augmentative procedures also include implanted drug-delivery systems. In these systems, catheters are implanted in the spine to allow direct delivery of drugs to the CNS.

Ablative procedures are characterized by severing a nerve and disconnecting it from the CNS. However, this method may not address potential alterations within the spinal cord. These changes perpetuate pain messages and do not cease even when the connection between the sensory nerve and the CNS is severed. With growing understanding of neuropathic pain and development of less invasive procedures, ablative procedures are used less frequently. However, they do have applications in select cases of peripheral neuropathy, cancer pain, and other disorders.

— Julia Barrett

Definition

If pain can be defined as a highly unpleasant, individualized experience of one of the body's defense mechanisms indicating an injury or problem, pain management encompasses all interventions used to understand and ease pain, and, if possible, to alleviate the cause of the pain.

Purpose

Pain serves to alert a person to potential or actual damage to the body. The definition for damage is quite broad: pain can arise from injury as well as disease. After the message is received and interpreted, further pain can be counterproductive. Pain can have a negative impact on a person's quality of life and impede recovery from illness or injury, thus contributing to escalating health care costs. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person's health and outlook. Managing pain properly facilitates recovery, prevents additional health complications, and improves an individual's quality of life.

Yet, the experiencing of pain is a completely unique occurrence for each person, a complex combination of several factors other than the pain itself. It is influenced by:

• Ethnic and cultural values. In some cultures, tolerating pain is related to showing strength and endurance. In others, it is considered punishment for misdeeds.
• Age. This refers to the concept that grownups never cry.
• Anxiety and stress. This is related to being in a strange, fearful place such as a hospital, and the fear of the unknown consequences of the pain and the condition causing it, which can all combined to make pain feel more severe. For patients being treated for pain, knowing the duration of activity of an analgesic leads to anxiety about the return of pain when the drug wears off. This anxiety can make the pain more severe.
• Fatigue and depression. It is known that pain in itself can actually cause depression. Fatigue from lack of sleep or the illness itself also contribute to depressed feelings.

Precautions

The perception of pain is an individual experience. Health care providers play an important role in understanding their patients' pain. All too often, both physicians and nurses have been found to incorrectly assess the severity of pain. A study reported in the Journal of Advanced Nursing evaluated nurses' perceptions of a select group of white American and Mexican-American women patients' pain following gallbladder surgery. Objective assessments of each patient's pain showed little difference between the perceived severities for each group. Yet, the nurses involved in the study consistently rated all patients' pain as less than the patients reported, and with equal consistency, believed that better-educated women born in the United States were suffering more than less-educated Mexican-American women. Nurses from a northern European background were more apt to minimize the severity of pain than nurses from eastern and southern Europe or Africa. The study indicated how health care staff, and especially nursing staff, need to be aware of how their own background and experience contributes to how they perceive a person's pain.

In a 1990 study reported in the journal Pain, nurses were found to overestimate the severity of pain in patients with severe burns. In most other studies, nurses and physicians ascribe a lower pain severity than do patients.

Description

Before considering pain management, a review of pain definitions and mechanisms may be useful. Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. PNS includes all nerves throughout the body, except the brain and spinal cord. Pain is sometimes categorized by its site of origin, either cutaneous (originating in the skin of subcutaneous tissue, such as a shaving nick or paper cut), deep somatic pain (arising from bone, ligaments and tendons, nerves, or veins and arteries), or visceral (appearing as a result of stimulation of pain receptor nerves around organs such as the brain, lungs, or those in the abdomen).

A pain message is transmitted to the CNS by special PNS nerve cells called nociceptors, which are distributed throughout the body and respond to different stimuli depending on their location. For example, nociceptors that extend from the skin are stimulated by sensations such as pressure, temperature, and chemical changes.

When a nociceptor is stimulated, neurotransmitters are released within the cell. Neurotransmitters are chemicals found within the nervous system that facilitate nerve cell communication. The nociceptor transmits its signal to nerve cells within the spinal cord, which conveys the pain message to the thalamus, a specific region in the brain.

Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural painkillers, called endorphins, to derail further pain messages from the same source. However, these natural painkillers may not adequately dampen a continuing pain message. Also, depending on how the brain has processed the pain information, certain hormones such as prostaglandins may be released. These hormones enhance the pain message and play a role in immune system responses to injury, such as inflammation. Certain neurotransmitters, especially substance P and calcitonin gene-related peptide, actively enhance the pain message at the injury site and within the spinal cord.

Pain is generally divided into two additional categories: acute and chronic. Nociceptive pain, or the pain that is transmitted by nociceptors, is typically called acute pain. This kind of pain is associated with injury, headaches, disease, and many other conditions. Response to acute pain is made by the sympathetic nervous system (the nerves responsible for the fight-or-flight response of the body). It normally resolves once the condition that precipitated it is resolved.

Following some disorders, pain does not resolve. Even after healing or a cure has been achieved, the brain continues to perceive pain. In this situation, the pain may be considered chronic. Chronic pain is within the province of the parasympathetic nervous system, and the changeover occurs as the body attempts to adapt to the pain. The time limit used to define chronic pain typically ranges from three to six months, although some health care professionals prefer a more flexible definition, and consider chronic pain as pain that endures beyond a normal healing time. The pain associated with cancer; persistent and degenerative conditions; and neuropathy, or nerve damage, is included in the chronic category. Also, unremitting pain that lacks an identifiable physical cause such as the majority of cases of low back pain may be considered chronic. The underlying biochemistry of chronic pain appears to be different from regular nociceptive pain.

It has been hypothesized that uninterrupted and unrelenting pain can induce changes in the spinal cord. In the past, severing a nerve's connection to the CNS has treated intractable pain. However, the lack of any sensory information being relayed by that nerve can cause pain transmission in the spinal cord to go into overdrive, as evidenced by the phantom limb pain experienced by amputees. Evidence is accumulating that unrelenting pain or the complete lack of nerve signals increases the number of pain receptors in the spinal cord. Nerve cells in the spinal cord may also begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Immune chemicals, primarily cytokines, may play a prominent role in such changes.

Managing Pain

Considering the different causes and types of pain, as well as its nature and intensity, management can require an interdisciplinary approach. The elements of this approach include treating the underlying cause of pain, pharmacological and non-pharmacological therapies, and some invasive (surgical) procedures.

Treating the cause of pain underpins the idea of managing it. Injuries are repaired, diseases are diagnosed, and certain encounters with pain can be anticipated and treated prophylactically (by prevention). However, there are no guarantees of immediate relief from pain. Recovery can be impeded by pain and quality of life can be damaged. Therefore, pharmacological and other therapies have developed over time to address these aspects of disease and injury.

Pharmacological Options

General guidelines developed by the World Health Organization (WHO) have been developed for pain management. These guidelines operate upon the following three-step ladder approach:

• Mild pain is alleviated with acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs and acetaminophen are available as over-the-counter and prescription medications, and are frequently the initial pharmacological treatment for pain. These drugs can also be used as adjuncts to the other drug therapies that might require a doctor's prescription. NSAIDs include aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters. Acetaminophen is also effective against pain, but its ability to reduce inflammation is limited. NSAIDs and acetaminophen are effective for most forms of acute (sharp, but of a short duration) pain.
• Mild to moderate pain is eased with a milder opioid medication, plus acetaminophen or NSAIDs. Opioids are both actual opiate drugs such as morphine and codeine, and synthetic drugs based on the structure of opium. This drug class includes drugs such as oxy-codon, methadone, and meperidine (Demerol). They provide pain relief by binding to specific opioid receptors in the brain and spinal cord.
• Moderate to severe pain is treated with stronger opioid drugs, plus acetaminophen or NSAIDs. Morphine is sometimes referred to as the gold standard of palliative care as it is not expensive, can be given by starting with smaller doses and gradually increased, and is highly effective over a long period of time. It can also be given by a number of different routes, including by mouth, rectally, or by injection.

Although antidepressant drugs were developed to treat depression, it has been discovered that they are also effective in combating chronic headaches, cancer pain, and pain associated with nerve damage. Antidepressants that have been shown to have analgesic (pain-reducing) properties include amitriptyline (Elavil), trazodone (Desyrel), and imipramine (Tofranil). Anticonvulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) and carbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.

Close monitoring of the effects of pain medications is required in order to assure that adequate amounts of medication are given to produce the desired pain relief. When a person is comfortable with a certain dosage of medication, oncologists typically convert to a long-acting version of that medication. Transdermal fentanyl patches (Duragesic) are a common example of a long-acting opioid drug often used for cancer pain management. A patch containing the drug is applied to the skin and continues to deliver the drug to the person for typically three days. Pumps are also available that provide an opioid medication upon demand when the person is experiencing pain. By pressing a button, they can release a set dose of medication into an intravenous solution or an implanted catheter. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Because these pumps offer the patient some degree of control over the amount of analgesic administered, the system, commonly called patient controlled analgesia (PCA), reduces the level of anxiety about availability of pain medication. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug. Research is underway to develop toxic substances that act selectively on nerve cells that carry pain messages to the brain. These substances would kill the selected cells and thus stop transmission of the pain message.

Non-Pharmacological Options

Pain treatment options that do not use drugs are often used as adjuncts to, rather than replacements for, drug therapy. One of the benefits of non-drug therapies is that an individual can take a more active stance against pain. Relaxation techniques such as yoga and meditation are used to focus the brain elsewhere than on the pain, decrease muscle tension, and reduce stress. Tension and stress can also be reduced through biofeedback, in which an individual consciously attempts to modify skin temperature, muscle tension, blood pressure, and heart rate.

Participating in normal activities and exercising can also help control pain levels. Through physical therapy, an individual learns beneficial exercises for reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body's natural painkillers.

Acupuncture involves the insertion of small needles into the skin at key points. Acupressure uses these same key points, but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged are very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupting pain signals and inducing release of endorphins. To be effective, use of TENS should be medically supervised.

Invasive Procedures

There are three types of invasive procedures that may be used to manage or treat pain: anatomic, augmentative, and ablative. These procedures involve surgery, and certain guidelines should be followed before carrying out a procedure with permanent effects. First, the cause of the pain must be clearly identified. Next, surgery should be done only if noninvasive procedures are ineffective. Third, any psychological issues should be addressed. Finally, there should be a reasonable expectation of success.

Anatomic procedures involve correcting the injury or removing the cause of pain. Relatively common anatomic procedures are decompression surgeries such as repairing a herniated disk in the lower back or relieving the nerve compression related to carpal tunnel syndrome. Another anatomic procedure is neurolysis, also called a nerve block, which involves destroying a portion of a peripheral nerve.

Augmentative procedures include electrical stimulation or direct application of drugs to the nerves that are transmitting the pain signals. Electrical stimulation works on the same principle as TENS. In this procedure, instead of applying the current across the skin, electrodes are implanted to stimulate peripheral nerves or nerves in the spinal cord. Augmentative procedures also include implanted drug-delivery systems. In these systems, catheters are implanted in the spine to allow direct delivery of drugs to the CNS.

Ablative procedures are characterized by severing a nerve and disconnecting it from the CNS. However, this method may not address potential alterations within the spinal cord. These changes perpetuate pain messages and do not cease, even when the connection between the sensory nerve and the CNS is severed. With growing understanding of neuropathic pain and development of less invasive procedures, ablative procedures are used less frequently. However, they do have applications in select cases of peripheral neuropathy, cancer pain, and other disorders.

Preparation

Prior to beginning management, pain is thoroughly evaluated. Pain scales or questionnaires are used to attach an objective measure to a subjective experience. Objective measurements allow health care workers to better understand the pain being suffered by the patient. Evaluation also includes physical examinations and diagnostic tests to determine underlying causes. Some evaluations require assessments from several viewpoints, including neurology, psychiatry and psychology, and physical therapy. If pain is due to a medical procedure, management consists of anticipating the type and intensity of associated pain and managing it preemptively.

Nurses or physicians often take what is called a pain history. This will help to provide important information that can help health care providers to better manage the patient's pain. A typical pain history includes the following questions:

• Where is the pain located?
• On a scale of 1 to 10, with 1 indicating the least pain, how would the person rate the pain being experienced?
• What does the pain feel like?
• When did (or does) the pain start?
• How long has the person had it?
• Is the person sometimes free of pain?
• Does the person know of anything that triggers the pain, or makes it worse?
• Does the person have other symptoms (nausea, dizziness, blurred vision, etc.) during or after the pain?
• What pain medications or other measures has the person found to help in easing the pain?
• How does the pain affect the person's ability to carry on normal activities?
• What does it mean to the person that he or she is experiencing pain?

Aftercare

An assessment by nursing staff as well as other health care providers should be made to determine the effectiveness of the pain management interventions employed. There are objective, measurable signs and symptoms of pain that can be looked for. The goal of good pain management is the absence of these signs. Signs of acute pain include:

• rise in pulse and blood pressure
• more rapid breathing
• perspiring profusely, clammy skin
• taut muscles
• more tense appearance, fast speech, very alert
• unusually pale skin
• dilated pupils of the eye

Signs of chronic pain include:

• lower pulse and blood pressure
• changeable breathing pattern
• warm, dry skin
• nausea and vomiting
• slow speech in monotone
• inability, or difficulty in getting out of bed and doing activities
• constricted pupils of the eye

When these signs are absent and the patient appears to be comfortable, health care providers can consider their interventions to have been successful. It is also important to document interventions used, and which ones were successful.

Risks

Owing to toxicity over the long term, some drugs can only be used for acute pain or as adjuncts in chronic pain management. NSAIDs have the well-known side effect of causing gastrointestinal bleeding, and long-term use of acetaminophen has been linked to kidney and liver damage. Other drugs, especially narcotics, have serious side effects such as constipation, drowsiness, and nausea. Serious side effects can also accompany pharmacological therapies; mood swings, confusion, bone thinning, cataract formation, increased blood pressure, and other problems may discourage or prevent use of some analgesics.

Non-pharmacological therapies carry little or no risks. However, it is advised that individuals recovering from serious illness or injury consult with the health care providers or physical therapists before making use of adjunct therapies. Invasive procedures carry risks similar to other surgical procedures, such as infection, reaction to anesthesia, and iatrogenic (injury as a result of treatment) injury.

A traditional concern about narcotics use has been the risk of promoting addiction. As narcotic use continues over time, the body becomes accustomed to the drug and adjusts normal functions to accommodate to its presence. Therefore, to elicit the same level of action, it is necessary to increase dosage over time. As dosage increases, an individual may become physically dependent on narcotic drugs.

However, physical dependence is different from psychological addiction. Physical dependence is characterized by discomfort if drug administration suddenly stops, while psychological addiction is characterized by an overpowering craving for the drug for reasons other than pain relief. Psychological addiction is a very real and necessary concern in some instances, but it should not interfere with a genuine need for narcotic pain relief. However, caution must be taken with people who have a history of addictive behavior.

Normal Results

Effective application of pain management techniques reduces or eliminates acute or chronic pain. This treatment can improve an individual's quality of life and aid in recovery from injury and disease.

Resources

Books

Kozier, Barbara, Glenora Erb, Kathleen Blais, and Judith M. Wilkinson. Fundamentals of Nursing, Concepts, Process and Practice, 5th edition. Redwood City, CA: Addison-Wesley, 1995.

Salerno, Evelyn, and Joyce S. Willens, eds. Pain ManagementHandbook: An Interdisciplinary Approach. St. Louis: Mosby, 1996.

Periodicals

Choiniere, M., R. Melzack, N. Girard, J. Rondeau, and M. J. Paquin. "Comparisons between Patients' and Nurses' Assessment of Pain and Medication Efficacy in Severe Burn Injuries." Pain 40, no.2 (February 1990): 143–52.

Everett, J. J., D. R. Patterson, J. A. Marvin, B. Montgomery, N. Ordonez, and K. Campbell. "Pain Assessment from Patients with Burns and Their Nurses." Journal of Burn Care Rehabilitation 15, no.2 (Mar–Apr 1994): 194–8.

McPherson, M. L., C. D. Ponte, and R. M. Respond (eds.). "Profiles in Pain Management." Journal of the American Pharmacists Association (June 2003).

Organizations

American Chronic Pain Association. P.O. Box 850, Rocklin, CA 95677-0850. (916) 632-0922. http://members.tripod.com/~widdy/acpa.html.

American Pain Society. 4700 West Lake Ave., Glenview, IL 60025. (847) 375-4715. http://www.ampainsoc.org.

National Chronic Pain Outreach Association, Inc. P.O. Box 274, Millboro, VA 24460-9606. (540) 597-5004.

Other

What We Know About Pain. National Institute of Dental Research, National Institute of Health, Bethseda, MD 20892. (301) 496-4261.

— Joan M. Schonbeck Sam Uretsky, PharmD

Key Terms: Acute, Chemotherapy, Chronic, CNS or central nervous system, Hepatic capsule, Iatrogenic, Metastasis, Neuropathy, Neurotransmitter, Nociceptor, Non-pharmacological, Palliative, Pharmacological, PNS or peripheral nervous system, Radiation, Stimulus.

Definition

Pain management in cancer care encompasses all the actions taken to keep people with cancer as free of pain as possible. It includes pharmacological, psychological, and spiritual approaches to prevent, reduce, or stop pain sensations.

Purpose

It is estimated that more than 800,000 new cases of cancer are diagnosed each year in the United States, and 430,000 cancer victims will die. Though recent figures are hopeful and suggest a decline in both the incidence of cancer and the number of people who die from it, studies have consistently shown that at least 70% of cancer patients in the advanced stage of the disease will experience significant pain. Pain is a localized sensation ranging from mild discomfort to an unbearable, excruciating experience. It is, in its origins, a protective mechanism, designed to alert the brain to injury or disease conditions. Unfortunately, when the cause of the pain is known, such as in diagnosed cancer, and treatment is initiated, pain can often continue.

Once the message of cancer has been received and interpreted by the brain, further pain can be counter-productive. Pain can have a negative impact on a person's quality of life, causing depression and impeding recovery. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person's health and outlook. Proper pain management facilitates recovery, prevents additional health complications, and improves an individual's quality of life.

Several independent studies of the relief of pain have shown that pain is often under-treated by the medical profession. For this reason, in the spring and summer of 2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the American Pain Society (APS) developed standards for proper pain management.

Description

What Is Pain?

The treatment of pain has been a major endeavor since ancient times. By 400 B.C., the father of modern medicine, Hippocrates, had theorized that the brain, not the heart, was the controlling center of the body, and Greek anatomists had begun to identify various nerves and their purposes. The pain-relieving properties of opium were already known and were being utilized to stop suffering. Two thousand years ago, in China, acupuncture was being used to reduce pain.

Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. PNS includes all nerves throughout the body except the brain and spinal cord.

A pain message is transmitted to the CNS by special PNS nerve cells called nociceptors. Nociceptors are distributed throughout the body and respond to different stimuli depending on their location. For example, nociceptors that extend from the skin are stimulated by sensations such as pressure, temperature, and chemical changes.

When a nociceptor is stimulated, neurotransmitters are released from cells. Neurotransmitters are chemicals found within the nervous system that facilitate nerve cell communication. The nociceptor transmits its signal to nerve cells within the spinal cord, which conveys the pain message to the thalamus, a specific region in the brain.

Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural pain killers, called endorphins, that are meant to derail further pain messages from the same source. However, these natural pain killers may not adequately dampen a continuing pain message. Also, depending on how the brain has processed the pain information, certain hormones, such as prostaglandins, may be released. These hormones enhance the pain message and play a role in immune system responses to injury, such as inflammation. Certain neurotransmitters, especially substance P and calcitonin gene-related peptide, actively enhance the pain message at the injury site and within the spinal cord.

It has been hypothesized that uninterrupted and unrelenting pain can induce changes in the spinal cord. In the past, intractable pain (pain that can't be managed or cured) has been treated by severing a nerve's connection to the CNS. However, the lack of any sensory information being relayed by that nerve can cause pain transmission in the spinal cord to go into overdrive, as evidenced by the phantom limb pain experienced by amputees. Evidence is accumulating that unrelenting pain or the complete lack of nerve signals increases the number of pain receptors in the spinal cord. Nerve cells in the spinal cord may also begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Immune chemicals, primarily cytokines, may play a prominent role in such changes.

What Is Cancer Pain?

The majority of cancer pain results from a cancerous tumor pressing on organs, nerves, or bone. However, several studies by pain-pioneer Dr. John Bonica and others have shown that a predictable 78% of all cancer pain is indeed related to the disease, but an impressive 19% was found to be caused instead by treatment of the cancer. Three percent of all complaints of pain were unrelated to either the disease or treatment.

Cancer pain is generally divided into three categories:

• Visceral pain, usually caused by pressure resulting from the invasiveness of the tumor, expansion of the hepatic capsule, or injury caused by radiation or chemotherapy.
• Somatic pain often resulting from bone metastasis.
• Neuropathic pain, or pain caused by the pressure of a tumor on nerves, or the trauma to nerves resulting from either radiation, chemotherapy, or surgery.

Managing Cancer Pain

Pharmacological Options

General guidelines developed by the World Health Organization (WHO) for pain management apply to cancer pain management as well. These guidelines follow a three-step ladder approach:

• Mild pain is alleviated with acetominophen or nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs and acetaminophen are available as over-the-counter and prescription medications, and are frequently the initial pharmacological treatment for pain. These drugs can also be used as adjuncts to the other drug therapies, which might require a doctor's prescription. NSAIDs include aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters, such as prostaglandins. Acetaminophen is also effective against pain, but its ability to reduce inflammation is limited. NSAIDs and acetaminophen are effective for most forms of acute (sharp, but of a short course) pain.
• Mild to moderate pain is eased with a milder opioid medication plus acetominophen or NSAIDs. Opioids are both actual opiate drugs such as morphine and codeine, and synthetic drugs based on the structure of opium. This drug class includes drugs such as oxycodone, methadone, and meperidine (Demerol). They provide pain relief by binding to specific opioid receptors in the brain and spinal cord, and thus block the perception of pain.
• Moderate to severe pain is treated with stronger opioid drugs plus acetominophen or NSAIDs. Morphine is sometimes referred to as the "Gold Standard" of palliative care as it is not expensive, can be given starting with smaller doses and gradually increased, and is highly effective over a long period of time. It can also be administered orally (by mouth), rectally, or by injection. A newer method of administering morphine involves a patient-controlled delivery system implanted in the covering of the spinal cord. Researchers in North Carolina reported in late 2003 that the new system not only provided more effective pain relief, but also lowered the patients' use of morphine and the complications associated with long-term use of morphine. In general, the development of implantable pumps has greatly improved pharmacological approaches to pain management.

Although antidepressant drugs were developed to treat depression, they are also effective in combating chronic headaches, cancer pain, and pain associated with nerve damage. Antidepressants shown to have analgesic (pain reducing) properties include amitriptyline (Ela vil), trazodone (Desyrel), and imipramine (Tofranil). Anticonvulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) and carbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.

Close monitoring of the effects of pain medications is required in order to assure that adequate amounts of medication are given to produce the desired pain relief. When a person is comfortable with a certain dosage of medication, oncologists typically convert to a long-acting version of that medication. Transdermal fentanyl patches (Duragesic) are a common example of an long-acting opioid drug often used for cancer pain management. A patch containing the drug is applied to the skin where the drug is continuously absorbed by the body, usually for three days. Pumps are also available that provide an opioid medication upon demand when the person is experiencing pain. By pressing a button, they can release a set dose of medication into an intravenous solution or an implanted catheter. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug. Research is underway to develop toxic substances that act selectively on nerve cells that carry pain messages to the brain, killing these selected cells, and thus stopping transmission of the pain message.

Non-Pharmacological Options

Pain treatment options that do not involve drugs are often used as adjuncts to, rather than replacements for, drug therapy. One of the benefits of non-drug therapies is that an individual can take a more active stance against pain. Relaxation techniques, such as yoga and meditation, are used to shift the focus of the brain away from the pain, decrease muscle tension, and reduce stress. Tension and stress can also be reduced through biofeedback, in which an individual consciously attempts to modify skin temperature, muscle tension, blood pressure, and heart rate. A group of researchers in New York reported in 2003 that the hypnotic-like approaches—particularly imagery, relaxation techniques, and hypnotic suggestion—appear to be more effective in managing pain than other behavioral approaches.

Participating in normal activities and exercising can also help control pain levels. Through physical therapy, an individual learns beneficial exercises for reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body's natural pain killers.

Acupuncture involves the insertion of small needles into the skin at key points. The acupuncturist will usually stimulate points on the ear when treating cancer pain. Acupressure uses these same key points, but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged are very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupting pain signals and inducing release of endorphins. To be effective, use of TENS should be medically supervised.

A new method for managing pain in children with cancer is virtual reality, which works by distracting the child's attention from the pain and accompanying anxiety. Virtual reality has been used successfully in the treatment of anxiety disorders, and shows great promise in treating children suffering from cancer pain. Larger-scale studies are under way as of late 2003.

Preparation

Assessment of cancer pain is absolutely essential to good pain management. Pain scales or questionnaires are sometimes used to attach an objective measure to a subjective experience. Objective measurements allow health care workers a better understanding of the pain being suffered by the patient. Pain has been called "the fifth vital sign," (temperature, pulse, respiration and blood pressure being the other four vital signs), by the Veterans Administration. Evaluation also includes physical examinations and diagnostic tests to determine underlying cause of the pain. Some evaluations require assessments from several viewpoints, including neurology, psychiatry and psychology, and physical therapy.

Risks

Owing to toxicity over the long term, even non-prescription drugs must be carefully monitored in chronic pain management. NSAIDs have the well-known side effect of causing gastrointestinal bleeding, and long-term use of acetaminophen has been linked to kidney and liver damage. Other drugs, especially narcotics, have side effects such as constipation, drowsiness, and nausea. Sedation can often be reduced by the timing of when medication is taken (such as at bedtime), and constipation can be reduced by increasing the amount of fruits, vegetables, and whole-grain foods in the diet, or by the use of laxatives, stool softeners, or even enemas. Serious side effects can also accompany antidepressants and anticonvulsants, which may discourage or prevent their use depending upon the circumstances. These side effects include mood swings, confusion, bone thinning, cataract formation, increased blood pressure, and other problems.

Non-pharmacological therapies carry little or no risks. However, it is advised that individuals recovering from serious illness or injury consult with their health care providers or physical therapists before making use of adjunct therapies. Invasive procedures carry risks similar to other surgical procedures, such as infection, reaction to anesthesia, iatrogenic injury (injury as a result of treatment), and heart failure.

A traditional concern about narcotics use has been the risk of promoting addiction or tolerance. As narcotic use continues over time, as in terminal cancer, the body becomes accustomed to the drug and adjusts normal functions to accommodate to its presence. Therefore, to elicit the same level of action, it is necessary to increase dosage over time. Tolerance can be defined as a gradual lessening of the effectiveness of an opioid drug from continued use.

Many studies involving cancer patients have indicated that proper dosage of narcotic medication does not create an addiction to it. A major concern for many cancer patients though, is that the medication will stop working for them. Evidence suggests this is not true. A simple increase in the dose will usually cause the medication to relieve pain again. One of the biggest dangers is abruptly stopping an opioid medication or reducing the dose, as the person can then go into withdrawal, a potentially serious medical condition characterized by agitation, rapid heart rate, profuse sweating and sleeplessness.

However, physical dependence is different from psychological addiction. Physical dependence is characterized by discomfort if drug administration suddenly stops, while psychological addiction is characterized by an overpowering craving for the drug for reasons other than pain relief. Psychological addiction is a very real and necessary concern in some instances, but it should not interfere with a genuine need for narcotic pain relief.

Normal Results

Effective application of pain management techniques reduces or eliminates cancer pain. This treatment can improve an individual's quality of life and aid in recovery.

Questions to Ask the Doctor

• Does my type of cancer usually cause pain, and if so, how will the pain be treated?
• Does the radiation or chemotherapy that I may have cause pain?
• What are the side-effects of the medications you will order?
• What things can I do to help with my pain management?
• Does the pain necessarily mean that the cancer is getting worse?

Perhaps the best measure of the results of pain management for cancer patients would be the fulfillment of the recently developed Bill of Rights for Cancer Pain. It is as follows:

• You have the right to be believed about the severity of your pain.
• You have the right to have your pain controlled.
• You have the right to have pain resulting from treatments and procedures prevented, or at least minimized.
• You have the right to be treated with respect at all times when you need medication; to not be treated like a drug abuser.

Resources

Periodicals

Alimi, D., C. Rubino, E. Pichard-Leandri, et al. "Analgesic Effect of Auricular Acupuncture for Cancer Pain: A Randomized, Blinded, Controlled Trial." Journal of Clinical Oncology 21 (November 15, 2003): 4120–4126.

Gershon, J., E. Zimand, R. Lemos, et al. "Use of Virtual Reality as a Distractor for Painful Procedures in a Patient with Pediatric Cancer: A Case Study." Cyberpsychology and Behavior 6 (December 2003): 657–661.

Mundy, E. A., K. N. DuHamel, and G. H. Montgomery. "The Efficacy of Behavioral Interventions for Cancer Treatment-Related Side Effects." Seminars in Clinical Neuropsychiatry 8 (October 2003): 253–275.

Perron, Vincent, MD, and Ronald S. Schonwetter, MD. "Assessment and Management of Pain in Palliative Care Patients." Cancer Control: Journal of the Moffitt Cancer Center 27 (January 2001).

Rauck, R. L., D. Cherry, M. F. Boyer, et al. "Long-Term Intrathecal Opioid Therapy with a Patient-Activated, Implanted Delivery System for the Treatment of Refractory Cancer Pain." Journal of Pain 4 (October 2003): 441–447.

Rosenthal, K. "Implantable Pumps Deliver Innovative Pain Management." Nursing Management 34 (December 2003): 46–49.

Organizations

American Chronic Pain Association. PO Box 850, Rocklin, CA 95677-0850. (916) 632-0922. .

American Pain Society. 4700 West Lake Ave., Glenview, IL 60025. (847) 375-4715. .

Cancer Care, Inc. "Bill of Rights for Cancer Pain." .

National Cancer Institute. "Cancer Facts." [citedSeptember 26, 2000]. .

National Chronic Pain Outreach Association, Inc. PO Box 274, Millboro, VA 24460-9606. (540) 997-5004.

—Julia Barrett; Joan Schonbeck, R.N.; Rebecca J. Frey, Ph.D.

Definition

Pain management covers a number of methods to prevent, reduce, or stop pain sensations. These include the use of medications; physical methods such as ice and physical therapy; and psychological methods.

Purpose

Pain serves as an alert to potential or actual damage to the body. The definition for damage is quite broad; pain can arise from injury as well as disease. Pain that acts as a warning is called productive pain. After the message is received and interpreted, further pain offers no real benefit. Pain can have a negative impact on a person's quality of life and impede recovery from illness or injury. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person's health and outlook. Managing pain properly facilitates recovery, prevents additional health complications, and improves a person's quality of life.

For many years it was believed that infants do not feel pain the way older children and adults do. As of the early 2000s, however, there has been a better understanding of the problems of pain, even in infancy.

Description

Before considering pain management, a review of pain definitions and mechanisms may be useful.

What Is Pain?

Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. PNS includes all nerves throughout the body except the brain and spinal cord.

Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural pain killers, called endorphins, that are meant to derail further pain messages from the same source. However, these natural pain killers may not adequately dampen a continuing pain message. Pain is generally divided into two categories: acute and chronic.

Acute and Chronic Pain

Nociceptive pain, or the pain that is transmitted by nociceptors, is typically called acute pain. This kind of pain is associated with injury, headaches, disease, and many other conditions. It usually resolves once the condition that caused it is resolved. However, following some disorders, pain does not resolve. Even after healing or a cure has been achieved, the brain continues to perceive pain. In this situation, the pain may be considered chronic. The time limit used to define chronic pain typically ranges from three to six months, although some healthcare professionals prefer a more flexible definition and consider pain chronic when it endures beyond a normal healing time. The pain associated with cancer, persistent and degenerative conditions, and neuropathy, or nerve damage, is included in the chronic category. Also, constant pain that lacks an identifiable physical cause, such as the majority of cases of low back pain, may be considered chronic.

It has been hypothesized that uninterrupted and unrelenting pain can induce changes in the spinal cord. As of 2004 evidence was accumulating that unrelenting pain or the complete lack of nerve signals increases the number of pain receptors in the spinal cord. Nerve cells in the spinal cord may also begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Other studies indicate that even newborn and premature infants who have constant pain will reach adulthood with greater sensitivity to pain and lower tolerance of stress.

Managing Pain

Considering the different causes and types of pain, as well as its nature and intensity, management can require an interdisciplinary approach. The elements of this approach include treating the underlying cause of pain, pharmacological and nonpharmacological therapies, and some invasive (surgical) procedures.

Treating the cause of pain underpins the idea of managing it. Injuries are repaired, diseases are diagnosed, and certain encounters with pain can be anticipated and prevented. However, there are no guarantees of immediate relief from pain. Recovery can be impeded by pain, and quality of life can be damaged.

Pharmacological Options

Pain-relieving drugs, otherwise called analgesics, include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, narcotics, antidepressants, anticonvulsants, and others. NSAIDs and acetaminophen are available as over-the-counter and prescription medications and are frequently the initial pharmacological treatment for pain. These drugs can also be used as adjuncts to other drug therapies, which might require a doctor's prescription.

NSAIDs include aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters, such as prostaglandins. Acetaminophen is also effective against pain, but it is not an anti-inflammatory drug.

NSAIDs and acetaminophen are effective for most forms of mild pain, but moderate and severe pain may require stronger medication. Narcotics handle intense pain effectively and are used for cancer pain and acute pain that does not respond to NSAIDs and acetaminophen.

Narcotics may be ineffective against some forms of chronic pain, especially since changes in the spinal cord may alter the usual pain signaling pathways. Furthermore, narcotics are usually not recommended for long-term use because the body develops a tolerance to narcotics, reducing their effectiveness over time. In such situations, pain can be managed with antidepressants and anticonvulsants, which are also only available with a doctor's prescription.

Although antidepressant drugs were developed to treat depression, it has been discovered that they are also effective in combating chronic headaches, cancer pain, and pain associated with nerve damage. Antidepressants that have been shown to have analgesic (pain reducing) properties include amitriptyline (Elavil), trazodone (Desyrel), and imipramine (Tofranil). Anticonvulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) and carbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.

Other prescription drugs are used to treat specific types of pain or specific pain syndromes. For example, corticosteroids are very effective against pain caused by inflammation and swelling, and sumatriptan (Imitrex) was developed to treat migraine headaches.

Drug administration depends on the drug type and the required dose. Some drugs are not absorbed very well from the stomach and must be injected or administered intravenously. Injections and intravenous administration may also be used when high doses are needed or if an individual is nauseous. Following surgery and other medical procedures, patients may have the option of controlling the pain medication themselves. By pressing a button, they can release a set dose of medication into an intravenous solution. This procedure has also been employed in other situations requiring pain management. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug.

Nonpharmacological Options

Pain treatment options that do not use drugs are often used as adjuncts to, rather than replacements for, drug therapy. One of the benefits of non-drug therapies is that an individual can take a more active stance against pain. Relaxation techniques, such as yoga and meditation, are used to decrease muscle tension and reduce stress. Tension and stress can also be reduced through biofeedback, in which an individual consciously attempts to modify skin temperature, muscle tension, blood pressure, and heart rate.

Participating in normal activities and exercising can also help control pain levels. Through physical therapy, an individual learns beneficial exercises for reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body's natural pain killers.

Acupuncture involves the insertion of small needles into the skin at key points. Acupressure uses these same key points but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged are very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupt pain signals and induce the release of endorphins. To be effective, use of TENS should be medically supervised.

Invasive Procedures

Three types of invasive procedures may be used to manage or treat pain: anatomic, augmentative, and ablative. These procedures involve surgery, and certain guidelines should be followed before carrying out a procedure with permanent effects. First, the cause of the pain must be clearly identified. Next, surgery should be done only if noninvasive procedures are ineffective. Third, any psychological issues should be addressed. Finally, there should be a reasonable expectation of success.

Anatomic procedures involve correcting the injury or removing the cause of pain. Relatively common anatomic procedures are decompression surgeries, such as repairing a herniated disk in the lower back or relieving the nerve compression related to carpal tunnel syndrome. Another anatomic procedure is neurolysis, also called a nerve block, which involves destroying a portion of a peripheral nerve.

Augmentative procedures include electrical stimulation or direct application of drugs to the nerves that are transmitting the pain signals. Electrical stimulation works on the same principle as TENS. In this procedure, instead of applying the current across the skin, electrodes are implanted to stimulate peripheral nerves or nerves in the spinal cord.

Ablative procedures are characterized by severing a nerve and disconnecting it from the spinal cord.

Preparation

Prior to beginning management, pain is thoroughly evaluated. Pain scales or questionnaires are used to attach an objective measure to a subjective experience. Objective measurements allow healthcare workers a better understanding of the pain being experienced by the patient. Evaluation also includes physical examinations and diagnostic tests to determine underlying causes. Some evaluations require assessments from several viewpoints, including neurology, psychiatry, psychology, and physical therapy. If pain is due to a medical procedure, management consists of anticipating the type and intensity of associated pain and managing it preemptively.

Risks

Owing to toxicity over the long term, some drugs can only be used for acute pain or as adjuncts in chronic pain management. NSAIDs have the well-known side effect of causing gastrointestinal bleeding, and long-term use of acetaminophen has been linked to kidney and liver damage. Other drugs, especially narcotics, have serious side effects, such as constipation, drowsiness, and nausea. Serious side effects can also accompany pharmacological therapies; mood swings, confusion, bone thinning, cataract formation, increased blood pressure, and other problems may discourage or prevent use of some analgesics.

Nonpharmacological therapies carry little or no risk. However, it is advised that individuals recovering from serious illness or injury consult with their healthcare providers or physical therapists before making use of adjunct therapies. Invasive procedures carry risks similar to other surgical procedures, such as infection, reaction to anesthesia, iatrogenic (injury as a result of treatment) injury, and failure.

A traditional concern about narcotics use has been the risk of promoting addiction. As narcotic use continues over time, the body becomes accustomed to the drug and adjusts normal functions to accommodate to its presence. Therefore, to elicit the same level of action, it is necessary to increase dosage over time. As dosage increases, an individual may become physically dependent on narcotic drugs.

However, physical dependence is different from psychological addiction. Physical dependence is characterized by discomfort if drug administration suddenly stops, while psychological addiction is characterized by an overpowering craving for the drug for reasons other than pain relief. Psychological addiction is a very real and necessary concern in some instances, but it should not interfere with a genuine need for narcotic pain relief. However, caution must be taken with people with a history of addictive behavior.

Parental Concerns

Infants feel pain, but do not express it in the same manner as older children or young adults. Studies indicate that the majority of parents do not know how to recognize the signs of infant pain, and pediatricians fail to teach parents what to look for. Training of parents is essential in recognizing and dealing with pain in infants and young children.

In some cases, narcotic analgesics are essential for control of childhood pain. These drugs are safe when used properly and should not be withheld for fear of addiction.

Because exposure to chronic pain by children can lead to life-long changes in their pain response, parents must learn to recognize and treat pain promptly.

Over-the-counter pain relievers may be toxic. Parents must read the labeled directions carefully and follow them exactly. For liquids, it is essential to use the proper measuring devices, such as a measuring dropper or medicinal teaspoon. Household measures are not reliable.

See also Acetaminophen; Nonsteroidal anti-inflammatory drugs.

Resources

Periodicals

Byers, J. F., and K. Thornley. "Cueing into infant pain." MCN American Journal of Maternal and Child Nursing 29, no. 2 (March-April 2004): 84–89.

Stinshoff V. J., et al. "Effect of sex and gender on drug-seeking behavior during invasive medical procedures." Academy of Radiology 11, no. 4 (April 2004: 390–397.

Organizations

American Chronic Pain Association. PO Box 850, Rocklin, CA 95677–0850. Web site: .

American Pain Society. 4700 West Lake Ave., Glenview, IL 60025. Web site: www.ampainsoc.org.

Web Sites

"Instructions for the Infant Pain Scale." Virtual Children's Hospital, Acute Pain Management for Pediatric Patients. Available online at www.vh.org/pediatric/provider/pediatrics/PediatricPainMgmt/infantpainscale.html (accessed on September 28, 2004).

"Riley Infant Pain Scale Assessment Tool." Cancer Pain Management in Children. Available at www.childcancerpain.org/content.cfm?content=assess09 (accessed September 28, 2004).

[Article by: Julia Barrett Samuel Uretsky, PharmD]

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Pain management (also called pain medicine) is the medical discipline concerned with the relief of pain.

Contents 1 Types of pain 2 Methods 3 Medical specialties 4 See also 5 References 6 Further reading 7 External links

Types of pain

Acute pain, such pain resulting from trauma, often has a reversible cause and may require only transient measures and correction of the underlying problem. In contrast, chronic pain often results from conditions that are difficult to diagnose and treat, and that may take a long time to reverse. Some examples include cancer, neuropathy, and referred pain. Often, pain pathways (nociceptors) are set up that continue to transmit the sensation of pain even though the underlying condition or injury that originally caused pain has been healed. In such situations, the pain itself is frequently managed separately from the underlying condition of which it is a symptom, or the goal of treatment is to manage the pain with no treatment of any underlying condition (e.g. if the underlying condition has resolved or if no identifiable source of the pain can be found).

Methods

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), and psychological measures (such as biofeedback and cognitive therapy). The World Health Organization (WHO) recommended a pain ladder for managing analgesia^[1] which was first described for usage in cancer pain, but can be used by medical professionals as a general principle when dealing with analgesia for any type of pain.

Medical specialties

Pain management practitioners come from all fields of medicine. Most often, pain fellowship trained physicians are anesthesiologists, neurologists, physiatrists or psychiatrists. Palliative Care doctors are also specialists in pain management. Some practitioners have not been fellowship trained and have opted for certification by the American Board of Pain Medicine which is not recognized by the American Board of Medical Specialties and does not indicate fellowship training. Some practitioners focus more on the pharmacologic management of the patient, while others are very proficient at the interventional management of pain. Interventional procedures - typically used for chronic back pain - include: epidural steroid injections, facet joint injections, neurolytic blocks, Spinal Cord Stimulators and intrathecal drug delivery system implants, etc. Over the last several years the number of interventional procedures done for pain has grown to a very large number.

As well as medical practitioners, the area of pain management may often benefit from the input of Physiotherapists, Chiropractors, Clinical psychologists and Occupational therapists, amongst others. Together the multidisciplinary team can help create a package of care suitable to the patient. One of the pain management modalities are trigger point injections and nerve blocks utilizing long acting anesthetics and small doses of steroids.

Because of the fast growth in the field of Pain Medicine many practitioners have entered the field, with many of these practitioners being not board certified or being certified by unrecognized boards.

See also

• Neuralgia
• Neuropathy
• Temporomandibular joint disorder
• Transcutaneous electrical nerve stimulation

References

1. ^ WHO | WHO's pain ladder

Further reading

• Hilary J. Fausett; Warfield, Carol A. (2002). Manual of pain management. Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-2313-2. 
• Bajwa, Zahid H.; Warfield, Carol A. (2004). Principles and practice of pain medicine. New York: McGraw-Hill, Medical Publishing Division. ISBN 0-07-144349-5. 
• Waldman, Steven D. (2006). Pain Management. Philadelphia: Saunders. ISBN 0-7216-0334-3. 

External links

• Pain Management Resources: PainEdu

v • d • e Pain and nociception Head and neck Jaw and mouth (Odynophagia )  • Ear (otalgia, otitis media, otitis externa)  • Eye (glaucoma)  • Head (headache, migraine, tension headache, cluster headache, cerebral aneurysm, sinusitis, meningitis)  • Neck (atypical myocardial infarction) Thorax Back (upper back, lower back, spinal disc herniation, degenerative disc disease, coccydynia)  • Breast (perimenstrual, breast cancer)  • Chest (myocardial infarction, gastroesophageal reflux disease, pancreatitis, hiatus hernia, aortic dissection, asymptomatic pulmonary embolism, Tietze's syndrome)  • Shoulder (right side - cholecystitis) Abdominal Left and right upper quadrant (peptic ulcer disease, gastroenteritis, hepatitis, pancreatitis, cholecystitis, atypical myocardial infarction, abdominal aortic aneurysm, asymptomatic gastric cancer)  • Left and right lower quadrant (appendicitis, ulcerative colitis, Crohn's disease, ectopic pregnancy, endometriosis, pelvic inflammatory disease, diverticulitis, urolithiasis, pyelonephritis, colorectal cancer) Limbs Arm (myocardial infarction, left arm)  • Leg (deep vein thrombosis, peripheral artery occlusive disease, claudication, spinal disc herniation, sciatica) Joints (arthralgia) Small joints (osteoarthritis, rheumatoid arthritis, systemic lupus erythematosis, gout, pseudogout  • Large joints (osteoarthritis, septic arthritis, hemarthrosis, osteonecrosis)  • Back joints (ankylosing spondylitis, inflammatory bowel disease)  • Other (psoriatic arthritis, Reiter's syndrome) Musculoskeletal Delayed onset muscle soreness, myalgia, physical trauma Other/unspecified cold pressor test, congenital insensitivity to pain, dolorimeter, HSAN (Type I, II congenital sensory neuropathy, III familial dysautonomia, IV congenital insensitivity to pain with anhidrosis, V congenital insensitivity to pain with partial anhidrosis), neuralgia, pain asymbolia, pain disorder, paroxysmal extreme pain disorder  • Allodynia, breakthrough pain, chronic pain, hyperalgesia, hypoalgesia, hyperpathia, phantom pain, referred pain Related concepts Anterolateral system, gate control theory of pain, pain management (anesthesia, cordotomy), pain scale, pain threshold, pain tolerance, posteromarginal nucleus, substance P, suffering, OPQRST

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