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ESSENTIAL PAIN MANAGEMENT

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Title: Essential Pain Management Author: Wayne Morriss Last modified by: Wayne Morriss Created Date: 4/16/2012 9:35:37 AM Document presentation format – PowerPoint PPT presentation

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Title: ESSENTIAL PAIN MANAGEMENT


1
ESSENTIAL PAIN MANAGEMENT
1.1
2
EPM Aims
  • To improve understanding of pain
  • To teach a simple framework for managing pain
  • To reduce pain management barriers

1.2
3
Workshop Plan 1
  • Pain basics
  • What is pain?
  • Why should we treat pain?
  • Classification of pain
  • Physiology and pathology
  • Pain treatment
  • Barriers to treatment

1.3
4
Workshop Plan 2
  • Practical pain management
  • Case discussions
  • Overcoming barriers

1.4
5
Untreated Pain
1.5
6
Untreated Pain
  • Often hidden (not recognized)
  • Causes a lot of suffering
  • But can often be treated simply and cheaply

1.6
7
Approach to Pain
  • Recognize
  • Assess
  • Treat

1.7
8
Approach to PainR
  • Recognize
  • Does the patient have pain?
  • Do other people know the patient has pain?

1.8
9
Approach to PainA
  • Assess
  • How severe is the pain?
  • What type of pain is it?
  • Are there other factors?

1.9
10
Approach to PainT
  • Treat
  • What non-drug treatments can I use?
  • What drug treatments can I use?

1.10
11
?
1.11
12
IntroductionSummary
  • At the end of this course, you will be able to
  • Understand the importance of treating pain
  • Recognize, assess and treat different types of
    pain
  • Identify and address barriers where you work

1.12
13
What is Pain?
2.1
14
What is Pain?Aims
  • To define pain
  • To give examples of pain

2.2
15
What is Pain?
  • Group discussion
  • Think of a patient / friend / relative who had
    pain.
  • How did the person describe the pain?
  • How was it treated?

2.3
16
What is Pain?
  • International Association for the Study of Pain
  • Pain is "an unpleasant sensory and emotional
    experience associated with actual or potential
    tissue damage, or described in terms of such
    damage.
  • What does this mean?
  • Are there any other definitions?

2.4
17
What is Pain?
  • Unpleasant
  • Emotions are important
  • The cause is not always visible
  • Pain is what the patient says hurts.

2.5
18
Is this man feeling pain?
2.6
19
?
2.7
20
What is Pain?Summary
  • Pain is an unpleasant sensory and emotional
    experience
  • Pain is what the patient says hurts!

2.8
21
Why Should We Treat Pain?
3.1
22
Why Should We Treat Pain?Aims
  • To understand the reasons for treating pain
  • To understand the benefits for the patient,
    family and society

3.2
23
Case 1
  • Mr T is a 29-year-old man with a fast growing
    mouth cancer that has spread to his bones. He
    has severe face pain. He is expected to die
    within 6 months and the surgeons do not want to
    operate. He is married with two children, aged
    11 and 8
  • Why should we treat his pain?

3.3
24
Case 2
  • Mrs G is a 54-year-old woman who has just had a
    laparotomy for bowel obstruction. You see her on
    the surgical ward soon after the operation. She
    appears to be in pain.
  • Why should we treat her pain?

3.4
25
Why Pain Matters
  • For the patient
  • Physical
  • Suffering, poor sleep, decreased appetite
  • Medical complications
  • (e.g. heart attack, pneumonia)
  • Psychological
  • Depression, anxiety

3.5
26
Why Pain Matters
  • For the family
  • Unable to function as part of the family
  • (e.g. as a father / mother)
  • Lost income
  • For society
  • Greater health costs
  • (e.g. delayed hospital discharge)
  • Unable to contribute to the community

3.6
27
Painful SCC (xeroderma pigmentosum)
3.7
28
Advantages of Treating Pain
  • For the patient
  • Fewer physical and psychological problems
  • Greater dignity (esp. cancer pain)
  • For the family
  • Able to function as part of the family
  • Able to provide for family
  • For society
  • Lower health costs

3.8
29
?
3.9
30
Why Should We Treat Pain?Summary
  • Treating pain is the humane thing to do!
  • Treating pain has many benefits
  • For the patient
  • For the family
  • For society

3.10
31
Classification of Pain
4.1
32
Classification of PainAims
  • To classify types of pain
  • To understand that treatment depends on the pain
    type

4.2
33
Classification of Pain
  • Not all pain is the same!
  • Three main questions
  • How long has the patient had pain?
  • What is the cause?
  • What is the pain mechanism?

4.3
34
Classification of Pain
Duration Acute Chronic Acute on chronic
Cause Cancer Non-cancer
Mechanism Nociceptive (physiological) Neuropathic (pathological)
4.4
35
Acute versus Chronic
  • Acute
  • Pain of recent onset and probable limited
    duration
  • Chronic
  • Pain persisting beyond healing of injury
  • Often no identifiable cause
  • (Pain lasting for more than 3 months)

4.5
36
Cancer versus Non-Cancer
  • Cancer pain
  • Progressive
  • May be mixture of acute and chronic
  • Non-cancer pain
  • Many different causes
  • Acute or chronic
  • Can you give examples?

4.6
37
Invasive oral cancer
4.7
38
Nociceptive Pain
  • Obvious tissue injury or illness
  • Physiological pain
  • Description
  • Sharp dull
  • Well localised
  • Can you give examples?

4.8
39
Neuropathic Pain
  • Nervous system damage or abnormality
  • Pathological pain
  • Tissue injury may not be obvious
  • Description
  • Burning, shooting numbness, pins and needles
  • Not well localised
  • Can you give examples?

4.9
40
Examples of Pain Types
4.10
41
Acute Non-Cancer Pain
  • Examples
  • Fracture, appendicitis
  • Symptom of tissue injury or illness
  • Useful
  • Usually nociceptive
  • Occasionally neuropathic (e.g. sciatica)

4.11
42
Chronic Non-Cancer Pain
  • Examples
  • Headache, back pain
  • Usually no obvious injury
  • Not useful
  • Complex, may be mixed nociceptive and neuropathic
  • Does not respond to usual drug treatment

4.12
43
Cancer Pain
  • Examples
  • Oral cancer, uterine cervical cancer
  • Features of acute and chronic pain
  • May be acute on chronic
  • Often mixed nociceptive and neuropathic pain
  • Usually gets worse over time if untreated

4.13
44
?
4.14
45
Classification of PainSummary
  • Deciding on the type of pain is important
  • Acute / chronic
  • Cancer / non-cancer
  • Nociceptive / neuropathic
  • Treatment depends on the pain type

4.15
46
Pain Physiology and Pathology
5.1
47
Pain Physiology and PathologyAims
  • To understand normal pain physiology
  • Pain pathway
  • Factors affecting the pain signal
  • To understand the basis of neuropathic
    pain(pathology)

5.2
48
Nociception and Pain
  • Nociception
  • How pain signals get from the site of injury to
    the brain
  • Pain perception
  • How we feel pain
  • Nociception is not the same as pain!

5.3
49
Is this man feeling pain?
5.4
50
Nociception is not the same as pain!
Injury
Beliefs/concerns about pain
Other illnesses
Psychol. factors anxiety/anger/depression
Coping strategies
Cultural issues Language, expectations
Social factors e.g. family, work
Pain What the patient says hurts. What must be
treated.
5.5
51
Physiology
  • 4 steps
  • Periphery
  • Spinal cord
  • Brain
  • Modulation
  • We will look at each step

5.6
52
Periphery
  • Tissue injury
  • Release of chemicals
  • Stimulation of pain receptors (nociceptors)
  • Signal travels in Ad or C nerve to spinal cord

5.7
53
Spinal Cord
  • Dorsal horn is the first relay station
  • Ad or C nerve synapses (connects) with second
    nerve
  • Second nerve travels up opposite side of spinal
    cord

5.8
54
Brain
  • Thalamus is the second relay station
  • Connections to many parts of the brain
  • Cortex
  • Limbic system
  • Brainstem
  • Pain perception occurs in the cortex

5.9
55
Modulation
  • Descending pathway from brain to dorsal horn
  • Usually decreases pain signal

5.10
56
Why is pain physiology important?
  • Many factors affect how we feel pain.
  • Psychological factors are very important.
  • Different treatments work on different parts of
    the pathway.
  • More than one treatment may be needed.

5.11
57
Neuropathic Pain
  • Pathological pain
  • Abnormality of
  • Peripheral nerves
  • Spinal cord or brain
  • Needs to be treated differently

5.12
58
Neuropathic Pain
  • Peripheral
  • Damaged nerves (e.g. trauma, diabetes)
  • Abnormal firing of nerves
  • Central
  • Changes in wiring
  • Abnormal firing
  • Loss of modulation
  • How do patients describe their pain?

5.13
59
?
5.14
60
Pain Physiology and PathologySummary
  • Many factors affect how we feel pain.
  • Different treatments work on different parts of
    the pain pathway.
  • Neuropathic pain is pathological pain and needs
    to be treated differently.

5.15
61
Pain Treatment Overview
6.1
62
Pain Treatment OverviewAims
  • To discuss non-drug and drug treatments where you
    work
  • To classify pain treatments

6.2
63
Pain Treatment
  • Group discussion
  • What non-drug treatments are available where you
    work?
  • What drug treatments are available where you
    work?

6.3
64
Non-Drug Treatments
  • Physical
  • Rest, ice, compression, elevation
  • Surgery
  • Acupuncture, massage, physiotherapy
  • Psychological
  • Explanation
  • Reassurance
  • Counseling

6.4
65
Placebo Treatment
  • Group discussion
  • What is placebo?
  • Is it helpful or unhelpful?

6.5
66
Placebo Treatment
  • Psychological factors are important.
  • If a placebo treatment works, this does not mean
    the patient did not have pain or was telling lies!

6.6
67
Drug Classification
  • Simple analgesics
  • Paracetamol (acetaminophen)
  • Anti-inflammatory medicines
  • Aspirin, ibuprofen
  • Opioids
  • Mild
  • Codeine
  • Strong
  • Morphine, pethidine

6.7
68
Drug Classification
  • Other analgesics
  • Amitriptyline
  • Carbamazepine
  • Local anaesthetics
  • Ketamine
  • Tramadol
  • Clonidine
  • Entonox (N2O/O2)

6.8
69
Treatments - Periphery
  • Non-drug treatments
  • Rest, ice, compression, elevation
  • Anti-inflammatory medicines
  • Local anaesthetics

6.9
70
Treatments - Spinal Cord
  • Non-drug treatments
  • Acupuncture, massage
  • Local anaesthetics
  • Opioids
  • Ketamine

6.10
71
Treatments - Brain
  • Non-drug treatments
  • Psychological
  • Drug treatments
  • Paracetamol
  • Opioids
  • Amitriptyline
  • Clonidine

6.11
72
?
6.12
73
Pain Treatment OverviewSummary
  • Both non-drug and drug treatments are important.
  • Different treatments work on different parts of
    the pain pathway.
  • Analgesics can be classified into simple
    analgesics, opioids and other drugs.

6.13
74
Pain Drugs
7.1
75
Pain DrugsAims
  • To summarise the major advantages and
    disadvantages of important drugs
  • To discuss drug addiction

7.2
76
Paracetamol (Acetaminophen)
  • Advantages
  • Cheap, safe
  • Can be given orally or rectally
  • Good for
  • Mild pain (by itself)
  • Mod-severe pain (with other drugs)
  • Disadvantages
  • Liver damage in overdose

7.3
77
Anti-Inflammatory Medicines
  • Aspirin, ibuprofen
  • Advantages
  • Cheap, generally safe
  • Good for nociceptive pain
  • Best given regularly with paracetamol
  • Disadvantages
  • Gastrointestinal and renal side effects

7.4
78
Codeine
  • Advantages
  • Cheap, safe
  • Good for mild-moderate acute nociceptive pain
  • Best given regularly with paracetamol
  • Disadvantages
  • Constipation
  • Not good for chronic pain
  • Myths about addiction

7.5
79
Opioids and Addiction
  • Group discussion
  • Do opioids cause addiction?
  • Would this stop you giving opioids to a patient
    who has pain?

7.6
80
Opioids and Addiction
  • Pain is sometimes poorly treated because of
    concerns about addiction.
  • Addiction is very rare in
  • Acute pain
  • Cancer pain
  • Addiction is more likely in chronic non-cancer
    pain.

7.7
81
Morphine 1
  • Advantages
  • Cheap, generally safe
  • Can be given orally, IV, IM, SC
  • Effective if given regularly
  • Good for
  • Mod-severe acute nociceptive pain (e.g. post-op
    pain)
  • Chronic cancer pain

7.8
82
Morphine 2
  • Disadvantages
  • Constipation
  • Respiratory depression in high dose
  • Myths about addiction
  • Regulations about use

7.9
83
Pethidine
  • Advantages
  • Cheap
  • Can be given orally, IV, IM
  • Can be good for severe acute nociceptive pain
  • Disadvantages
  • Must be given more often than morphine
  • Breakdown product (norpethidine) can cause
    convulsions
  • Not good for chronic pain

7.10
84
Amitriptyline
  • Increases descending inhibitory signals
  • Advantages
  • Cheap, safe in low dose
  • Good for neuropathic pain
  • Also treats depression, poor sleep
  • Disadvantages
  • Anti-cholinergic side effects (glaucoma, urinary
    retention)

7.11
85
Anti-Epileptic Drugs
  • Carbamazepine (Tegretol)
  • Sodium valproate (Epilim)
  • Membrane stabilisers
  • Reduce abnormal firing of nerves
  • Good for neuropathic pain

7.12
86
Entonox (N2O/O2)
  • Advantages
  • Fast onset / fast offset
  • Good for
  • Labour pains
  • Short painful procedures (e.g. dressing changes)
  • Disadvantages
  • Need cylinder and mask

7.13
87
Drug Treatments
Acute noci mild Acute noci severe Acute neuro Chronic non-cancer Chronic cancer
Paracetamol
NSAIMs
Codeine
Morphine -
Amitriptyline - -
Carbamazepine - -
7.14
88
?
7.15
89
Pain DrugsSummary
  • Pain can be treated with relatively cheap and
    safe drugs.
  • Opioid addiction is rare in acute or cancer pain.

7.16
90
Barriers to Pain Treatment
8.1
91
Barriers to Pain TreatmentAims
  • To understand some of the reasons why pain may
    not be treated adequately
  • To think about some solutions

8.2
92
Barriers to Pain Treatment
  • Group Discussion
  • Pain is often not treated as well as it could be.
    What are some of the reasons for this?
  • Patients
  • Drugs
  • Health workers
  • System issues
  • What are the main barriers where you work?
  • What can be done about these barriers?

8.3
93
?
8.4
94
Barriers to Pain TreatmentSummary
  • There are many reasons why pain is not treated as
    well as it could be.
  • Important barriers are attitudes, lack of staff
    and lack of drugs.
  • How can YOU overcome these barriers where you
    work?

8.5
95
Basic Approach to Pain Management
9.1
96
Basic ApproachAims
  • To give a simple framework for managing patients
    with pain
  • To illustrate the use of this framework for
    different types of pain

9.2
97
Approach to Pain
9.3
98
Approach to Pain
  • Recognize
  • Assess
  • Treat

9.4
99
Approach to PainRecognize
  • Does the patient have pain?
  • Ask
  • Look (frowning, moving easily, sweating?)
  • Do other people know the patient has pain?
  • Other health workers
  • Patients family

9.5
100
Approach to PainAssess
  • Measure the severity
  • What is the pain score?
  • At rest
  • With movement
  • How is the pain affecting the patient?
  • Can the patient move, cough?
  • Can the patient work?

9.6
101
Measuring Pain
  • Helps guide treatment
  • Methods
  • Verbal (e.g. mild, moderate, severe)
  • Numerical
  • 0 (no pain) to 10 (worst pain imaginable)
  • Visual
  • Visual Analogue Scale (VAS)
  • Faces pain scale

9.7
102
Visual Analogue Scale
9.8
103
Faces Pain Scale
9.9
104
Approach to PainAssess
  • Make a pain diagnosis!
  • Acute or chronic?
  • Cancer or non-cancer?
  • Nociceptive or neuropathic?
  • Look for neuropathic features
  • Burning or shooting pain
  • Phantom limb pain
  • Other features (pins and needles, numbness)

9.10
105
Approach to PainAssess
  • Are there other factors?
  • Physical factors (other illnesses)
  • Psychological and social factors
  • Anger, anxiety, depression
  • Lack of social supports

9.11
106
Approach to PainTreat
  • Non-Drug Treatments
  • RICE
  • Rest, ice, compression, elevation of injuries
  • Nursing care
  • Surgery, acupuncture, massage etc
  • Psychological
  • Explanation and reassurance
  • Input from social worker / pastor

9.12
107
Approach to PainTreat
  • Drug Treatments Nociceptive Pain
  • Mild
  • Paracetamol ( NSAIM)
  • Moderate
  • Paracetamol ( NSAIM) codeine
  • Severe
  • Paracetamol ( NSAIM) morphine

9.13
108
Approach to PainTreat
  • Drug Treatments Neuropathic Pain
  • Traditional drugs may not be as useful
  • Use other drugs early
  • Amitriptyline
  • Carbamazepine
  • Dont forget non-drug treatments

9.14
109
Approach to PainExample 1
  • Mr D is a 32-year-old man who caught his right
    hand in a piece of machinery at work and now has
    a large open wound with several broken bones.
  • How would you manage his pain?

9.15
110
Approach to PainExample 2
  • Jon is an 8-year-old boy with probable
    appendicitis. He is in the Emergency Department
    and will have to wait several hours for an
    operation.
  • How would you manage his pain?

9.16
111
Approach to PainExample 3
  • Miss B is a 24-year-old woman who has a two year
    history of severe headache. She was seen at the
    regional hospital 6 months ago and was told that
    there was nothing wrong inside her head and she
    was going to have to live with the pain.
  • How would you manage her pain?

9.17
112
Approach to PainExample 4
  • Maria is a 12-year-old girl with burns to her
    chest and abdomen. She needs dressing changes
    every 2-3 days.
  • How would you manage her pain?

9.18
113
?
9.19
114
Approach to PainSummary
  • Recognize
  • Assess
  • Measure severity
  • Make a pain diagnosis
  • Consider other factors
  • Treat
  • Non-drug treatments
  • Drug treatments

9.20
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