Essential Pain Management. CC BY NC SA: This work is licensed under a Creative Commons Attribution NonCommerical ShareAlike 3.0 License.

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1 Essential Pain Management CC BY NC S: his work is licensed under a Creative Commons ttribution NonCommerical Sharelike 3.0 License.

2 Introduction 1.1 CC BY NC S: his work is licensed under a Creative Commons ttribution NonCommerical Sharelike 3.0 License.

3 1.2 Why EPM?

4 Why EPM? Pain is common. Pain is often poorly managed. We need a better system. 1.3

5 EPM is a system For managing pain For teaching others 1.4

6 System? rauma Multiple causes eam management BC system Pain Multiple causes eam management No system LS, PC training? 1.5

7 Overall EPM ims Better recognition Better assessment Better treatment 1.6

8 ecognize pain Workshop Objectives You will be able to: Define pain List benefits of treating pain ssess pain Measure severity Classify types of pain ssess other factors 1.7

9 reat pain Workshop Objectives You will be able to: List non pharmacological treatments List pharmacological treatments Devise an action plan to address local barriers. 1.8

10 Workshop Plan Short, interactive lectures Discussions on barriers and solutions Case discussions 1.9

11 1.10 Untreated Pain

12 Untreated Pain Often hidden (not recognized) Causes a lot of suffering But can often be treated simply and cheaply 1.11

13 System ecognize ssess reat 1.12

14 ecognize Does the patient have pain? Do other people know the patient has pain?

15 ssess How severe is the pain? What type of pain is it? re there other factors?

16 reat What non pharmacological treatments can I use? What pharmacological treatments can I use?

17 1.16

18 Introduction Summary Pain is common. Pain is often poorly treated. We need a better system. provides this system. 1.17

19 ecognize ssess reat 1.7 1

20 ecognize Does the patient have pain? Do other people know the patient has pain? he next lectures will cover: he definition of pain he benefits of treating pain 2

21 What is Pain? 2.1 CC BY NC S: his work is licensed under a Creative Commons ttribution NonCommerical Sharelike 3.0 License.

22 What is Pain? Objectives You will be able to: Define pain Use this definition to recognize pain 2.2

23 Group Discussion hink of a patient who has or had pain. How did he or she describe the pain? 2.3

24 Does this person have pain? 2.4

25 What is Pain? International ssociation for the Study of Pain (ISP) Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. re there any other definitions? 2.5

26 What is Pain? Pain is unpleasant. Emotions are important. he cause is not always visible. 'Pain is what the patient says hurts. 2.6

27 Does this person have pain? 2.7

28 2.8

29 What is Pain? Summary Pain is an unpleasant sensory and emotional experience. emember to ask! 2.9

30 Why Should We reat Pain? 3.1 CC BY NC S: his work is licensed under a Creative Commons ttribution NonCommerical Sharelike 3.0 License.

31 Why Should We reat Pain? Objectives You will be able to: List the benefits of treating pain: For the patient For the family For society 3.2

32 Case Discussion 1 Mrs is a 33 year old woman with uterine cervical cancer. he cancer has spread to her spine and she has disabling pain. he surgeons do not have any other options to treat her cancer. She is married with two children, aged 11 and 8. Why should we treat her pain? 3.3

33 Case Discussion 2 Mr G is a 54 year old man who has just had a laparotomy for bowel obstruction. You see him on the surgical ward soon after the operation. He complains of severe pain. Why should we treat his pain? 3.4

34 Benefits of reating Pain For the patient Physical Better sleep, improved appetite Fewer medical complications (e.g. heart attack, pneumonia) Psychological educed suffering Less depression, anxiety 3.5

35 Benefits of reating Pain For the family Improved function as part of the family (e.g. as a father / mother) ble to keep working For society educed health costs (e.g. shorter hospital stay) ble to contribute to the community 3.6

36 What are the benefits for this child? 3.7

37 Group Discussion re there any reasons for NO treating pain? 3.8

38 3.9

39 Why Should We reat Pain? Summary reating pain is the humane thing to do! reating pain has many benefits: For the patient For the family For society 3.10

40 ecognize ssess reat 1.7 1

41 ssess How severe is the pain? What type of pain is it? re there other factors? 2

42 ssess How severe is the pain? What is the pain score? How is the pain affecting the patient? 3

43 ssess What is the pain type? cute or chronic? Cancer or non cancer? Nociceptive or neuropathic? 4

44 ssess re there other factors? Physical? Psychological? 5

45 ssess he next lectures will cover: ssessment of severity Classification of pain Underlying physiology and pathology 6

46 ssessment of Severity 4.1 CC BY NC S: his work is licensed under a Creative Commons ttribution NonCommerical Sharelike 3.0 License.

47 ssessment of Severity Objectives You will be able to: Understand the reasons for assessing severity Use different methods to assess severity 4.2

48 ssessment of Severity Guides choice of treatment Measures response to treatment Pain is the 5 th vital sign. Measure and record severity 4.3

49 ssessment of Severity What is the pain score? t rest? With movement? How is the pain affecting the patient? Can the patient move, cough? Can the patient work? 4.4

50 Methods Verbal ating Scale Mild, moderate, severe 0 (no pain) to 10 (worst pain imaginable) Visual Visual nalogue Scale (VS) Faces Pain Scale (FPS) Other Functional ctivity Score (FS) More specialised methods 4.5

51 Visual nalogue Scale sk the patient to show what his/her pain is on a scale of 0 to

52 Faces Pain Scale 4.7

53 Functional ctivity Score Is pain limiting function? Steps Pain at rest (0 to 10) Pain during activity (0 to 10), e.g. deep breathing, getting out bed Score : No limitation B: Mild moderate limitation C: Severe limitation 4.8

54 4.9

55 ssessment of Severity Summary ssessment of severity guides treatment and measures response. Common methods include: Verbal ating Scale Visual nalogue Scale Faces Pain Scale 4.10

56 Classification of Pain 5.1 CC BY NC S: his work is licensed under a Creative Commons ttribution NonCommerical Sharelike 3.0 License.

57 Classification of Pain Objectives You will be able to: Classify types of pain Give examples of types of pain Understand that treatment depends on the pain type 5.2

58 Classification of Pain Not all pain is the same! hree main questions: 1. How long has the patient had pain? 2. What is the cause? 3. What is the pain mechanism? 5.3

59 Classification of Pain Duration cute Chronic Cause Cancer Non cancer Mechanism Nociceptive (physiological) Neuropathic (pathological) 5.4

60 cute versus Chronic cute Pain of recent onset and probable limited duration Chronic Pain lasting for more than 3 months Pain lasting after normal healing Sometimes no identifiable cause 5.5

61 Cancer versus Non Cancer Need one of sick patient / cancer 5.6

62 Cancer versus Non Cancer Cancer pain Progressive May be mixture of acute and chronic Non cancer pain Many different causes cute or chronic Can you give examples of non cancer pain? 5.7

63 Nociceptive Pain Obvious tissue injury or illness Sometimes called physiological pain Protective function Description Sharp and/or dull Well localised Can you give examples? 5.8

64 Neuropathic Pain Caused by a lesion or disease of the sensory nervous system issue injury may not be obvious Does not have a protective function Description Burning, shooting, pins and needles, or numbness Not well localised Can you give examples? 5.9

65 Examples of Pain ypes 5.10

66 cute Non Cancer Pain Examples Fracture, appendicitis Symptom of tissue injury or illness Usually nociceptive Occasionally neuropathic (e.g. sciatica) 5.11

67 How would you classify low back pain? 5.12

68 Chronic Non Cancer Pain Examples Chronic back pain, arthritis Cause may not be obvious Complex, may be mixed nociceptive and neuropathic Different pharmacological treatments may be needed 5.13

69 Cancer Pain Examples Uterine cervical cancer, breast cancer Metastases in bone Features of acute and chronic pain May be acute on chronic Often mixed nociceptive and neuropathic pain Usually gets worse over time if untreated 5.14

70 5.15

71 Classification of Pain Summary Deciding on the type of pain is important. cute / chronic Cancer / non cancer Nociceptive / neuropathic reatment depends on the pain type. 5.16

72 Pain Physiology and Pathology 6.1 CC BY NC S: his work is licensed under a Creative Commons ttribution NonCommerical Sharelike 3.0 License.

73 Pain Physiology and Pathology Objectives You will be able to: Understand normal pain physiology Nociceptive pathway Factors affecting pain perception Understand the basis of neuropathic pain (pathology) 6.2

74 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 is usually needed. 6.3

75 Nociception and Pain Nociception How pain signals get from the site of injury to the brain. Pain How we perceive or feel pain. Nociception is not the same as pain! 6.4

76 Is this man feeling pain? 6.5

77 Nociception is not the same as pain! Nociception Beliefs e.g. religion Psychol. factors e.g. anger, anxiety Cultural issues e.g. expectations Other illnesses e.g. cancer Personality Social factors e.g. family, work Pain What the patient says hurts. What must be treated. 6.6 Modified from nalgesic Expert Group. herapeutic Guidelines 2007

78 Physiology 4 steps: Periphery Spinal cord Brain Modulation We will look at each step. 6.7

79 Periphery issue injury elease of chemicals Stimulation of pain receptors (nociceptors) Signal travels in δ or C nerve to spinal cord. 6.8

80 Spinal Cord Dorsal horn is the first relay station. δ or C nerve synapses (connects) with second order nerve. Second order nerve travels up opposite side of spinal cord. 6.9

81 Brain halamus is the second relay station. Connections to many parts of the brain. Cortex Limbic system Brainstem Pain perception occurs in the brain. 6.10

82 Modulation Descending pathway from brain to dorsal horn. Usually inhibits pain signals from the periphery. 6.11

83 Neuropathic Pain Pathological pain bnormality of nociceptive pathway Peripheral nerves Spinal cord or brain Needs different pharmacological treatments How do patients describe their pain? 6.12

84 Neuropathic Pain Mechanisms bnormal nerve tissue, e.g. amputation neuroma bnormal firing of pain nerves Changes in chemical signalling in the dorsal horn bnormal nerve connections in the dorsal horn Loss of normal inhibitory function 6.13

85 6.14

86 Pain Physiology and Pathology Summary Nociception is not the same as pain. Physical and psychological factors affect how we feel pain. Different treatments work on different parts of the nociceptive pathway. Neuropathic pain needs different pharmacological treatments. 6.15

87 ecognize ssess reat 1.7 1

88 reat Non pharmacological treatments? Pharmacological treatments? he next lectures will cover: Non pharmacological and pharmacological treatments Pharmacology of common pain medications 2

89 Pain reatment Overview 7.1 CC BY NC S: his work is licensed under a Creative Commons ttribution NonCommerical Sharelike 3.0 License.

90 Pain reatment Overview Objectives You will be able to: Describe the non pharmacological and pharmacological treatments that are available Classify pain treatments Understand the role of placebo treatment 7.2

91 Group Discussion What non pharmacological treatments are available? What pharmacological treatments are available? 7.3

92 Non Pharmacological reatments Physical est, ice, compression, elevation Surgery cupuncture, massage, physiotherapy Psychological Explanation eassurance Counselling 7.4

93 Pharmacological reatments Simple analgesics Paracetamol (acetaminophen) nti inflammatory medicines, e.g. ibuprofen Opioids Mild, e.g. codeine, tramadol Strong, e.g. morphine, pethidine, oxycodone 7.5

94 Pharmacological reatments Other analgesics ricyclic antidepressants, e.g. amitriptyline nticonvulsants, e.g. carbamazepine, gabapentin Local anaesthetics Others, e.g. ketamine, clonidine 7.6

95 reatments Periphery Non pharm treatments est, ice, compression, elevation nti inflammatory medicines Local anaesthetics 7.7

96 reatments Spinal Cord Non pharm treatments cupuncture, massage Local anaesthetics Opioids Ketamine 7.8

97 reatments Brain Non pharm treatments Psychological Pharmacological treatments Paracetamol Opioids mitriptyline 7.9

98 Group Discussion What is a placebo treatment? Is it helpful or unhelpful? 7.10

99 Placebo reatment Psychological factors are important. If a placebo treatment works, this does not mean that the patient did not have pain or was telling lies! 7.11

100 7.12

101 Pain reatment Overview Summary Both non pharmacological and pharmacological treatments are important. Different treatments work on different parts of the nociceptive pathway. Pain medications can be classified into simple analgesics, opioids and other analgesics. 7.13

102 Pain Medications 8.1 CC BY NC S: his work is licensed under a Creative Commons ttribution NonCommerical Sharelike 3.0 License.

103 Pain Medications Objectives You will be able to: Outline broad principles of pharmacological treatment Summarise the major advantages and disadvantages of important medications ddress concerns about opioid addiction 8.2

104 Broad Principles his lecture: Gives a broad overview of pharmacological treatment in common situations Gives examples of medications For more detail, including doses: Case discussions EPM manual and EPM app 8.3

105 reatment of Cancer Pain WHO Ladder* Step 3 Severe pain Step 1 Mild pain Use simple analgesics Step 2 Moderate pain Use mild opioid e.g. codeine, tramadol Continue simple analgesics Use strong opioid e.g. morphine Continue simple analgesics 8.4 dd other medications for neuropathic pain e.g. amitriptyline, gabapentin *Modified

106 WHO Ladder Developed for cancer pain Emphasises oral treatment reats nociceptive pain May need other medications for neuropathic pain Don t forget non pharmacological treatments! 8.5

107 reatment of cute Nociceptive Pain Step 3 Severe pain Use strong opioid e.g. morphine lso use simple analgesics everse WHO Ladder Step 2 Moderate pain Use mild opioid e.g. codeine, tramadol Continue simple analgesics Step 1 Mild pain Continue simple analgesics 8.6

108 everse WHO Ladder Mainly useful for severe acute nociceptive pain rauma pain Post operative pain Start at the top and step down the ladder as the pain improves. 8.7

109 Chronic, Non Cancer Pain Non pharmacological treatments very important May need treatment for neuropathic pain ntidepressants, e.g. amitriptyline nticonvulsants, e.g. gabapentin Opioids are usually not helpful and may cause harm. 8.8

110 Examples of Pain Medications 8.9

111 Paracetamol (cetaminophen) Indications Mild nociceptive pain Moderate to severe nociceptive pain (with other medications) dvantages Cheap, safe PO, P, IV Disadvantages Liver damage in overdose 8.10

112 Ibuprofen Indications Mild, moderate or severe nociceptive pain dvantages Cheap Usually safe if given short term Disadvantages Gastric and renal side effects Interferes with blood clotting 8.11

113 ramadol Indications Nociceptive and neuropathic pain dvantages Safe Useful for different pain types Can be used with morphine Disadvantages Nausea and vomiting Confusion 8.12

114 Morphine 1 Indications Moderate to severe, acute, nociceptive pain Cancer pain dvantages Very effective Cheap Usually safe PO, IV, IM, SC 8.13

115 Morphine 2 Disadvantages Nausea and vomiting espiratory depression in high dose Constipation Misunderstandings about addiction Legal controls 8.14

116 Morphine Dosing Oral dose is 2 3 times IV / IM / SC dose. Why is this? olerance Increased dose needed over time Very high doses may be needed in cancer treatment 8.15

117 mitriptyline Indication Neuropathic pain dvantages Cheap Safe in low dose lso treats depression, poor sleep Disadvantages Harmful in overdose Dry mouth, drowsiness Urinary retention 8.16

118 Gabapentin Indication Neuropathic pain dvantages Safe and effective Disadvantages Drowsiness Dose needs to be increased slowly 8.17

119 Group Discussion What is addiction? How common is opioid addiction in patients with pain? Would this stop you giving opioids to a patient who has pain? 8.18

120 Opioids and ddiction ddiction hree C s Craving Loss of control Negative consequences (harm) ddiction is very rare in acute pain and cancer pain. ddiction may occur if strong opioids are used to treat chronic non cancer pain. 8.19

121 Group Discussion Name 3 5 other pain medications used to treat different types of pain. What are their: Indications? dvantages? Disadvantages? 8.20

122 Medication Effectiveness cute noci mild cute noci severe cute neuro Chronic noncancer Paracetamol NSIMs / +/ Codeine / ramadol Morphine Cs nticonvulsants Chronic cancer 8.21

123 8.22

124 Pain Medications Summary Pain can be treated with relatively cheap and safe drugs. Morphine is very effective for cancer pain and acute severe nociceptive pain. In general, strong opioids should be avoided in chronic non cancer pain. 8.23

125 Pain Management Barriers 9.1 CC BY NC S: his work is licensed under a Creative Commons ttribution NonCommerical Sharelike 3.0 License.

126 Pain Management Barriers Objectives You will be able to: Summarise local pain management barriers Develop a plan to address local barriers 9.2

127 Group Discussion Pain is often poorly managed. What are some of the reasons for this? Patient factors Medications Health workers System issues What are the main barriers where you work? 9.3

128 9.4

129 Pain Management Barriers Summary Pain is often poorly managed. Barriers include lack of knowledge, health worker attitudes and lack of medications. You can help to address these barriers where you work! 9.5

130 Using the System 10.1 CC BY NC S: his work is licensed under a Creative Commons ttribution NonCommerical Sharelike 3.0 License.

131 Using the System Objectives You will be able to: Summarise the system pply this system to different types of pain Understand the importance of reassessment 10.2

132 Using the System 10.3

133 Using the System ecognize ssess reat 10.4

134 Using the System ecognize ssess Severity? ype? Other factors? reat Non pharmacological treatments Pharmacological treatments 10.5

135 Using the System ecognize Does the patient have pain? sk Look Do other people know the patient has pain? Other health workers Patient s family 10.6

136 Using the System ssess How severe is the pain? Measure at rest Measure with movement 10.7

137 Using the System ssess What type of pain is it? cute or chronic? Cancer or non cancer? Nociceptive or neuropathic? 10.8

138 Using the System ssess re there other factors? Physical factors Underlying illness Other illnesses Psychological and social factors 10.9

139 Using the System reat Non Pharmacological reatments For both nociceptive and neuropathic pain Physical (e.g. rest, ice, elevation, physiotherapy, massage) Psychological (e.g. reassurance, explanation, counselling) 10.10

140 Using the System reat Pharmacological reatments Nociceptive Pain Consider paracetamol, NSIMs, tramadol, codeine, morphine Use combinations (e.g. paracetamol + NSIM + opioid) Use IV morphine for acute, severe pain 10.11

141 Using the System reat Pharmacological reatments Neuropathic Pain Consider using tramadol, tricyclic antidepressant (e.g. amitriptyline) or anticonvulsant (e.g. gabapentin) 10.12

142 Using the System eassess epeat Is your treatment working? re other treatments needed? 10.13

143 Using the System Example 1 32 year old man caught his right hand in machinery at work. He presents with a compound fracture of his hand. How would you manage his pain using? 10.14

144 Using the System Example 2 55 year old woman presents with a large breast tumour with spread to her spine. She has severe pain. How would you manage her pain using? 10.15

145 Using the System Example 3 51 year old man has a 2 year history of lower back pain which sometimes radiates down his right leg. He fell recently and is now having problems walking. How would you manage his pain using? 10.16

146 10.17

147 Using the System Summary ecognize ssess Severity? ype? Other factors? reat Non pharmacological treatments Pharmacological treatments eassess 10.18

148 facebook.com/essentialpainmanagement