PRIMARY CARE APPROACH TO PAIN MANAGEMENT

Dr. Nurver Turfaner, M.D., PhD, Assoc. Prof.

Istanbul University Cerrahpasa Medical Faculty Department of Family Medicine

PAIN ASSESMENT

• Pain: the 5th vital sign (pulse, blood pressure, temperature, respiration)

• an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

Factors influencing pain perception

• Age• Anxiety• Culture• Fear• Gender• Observational learning (family

history of pain/previous experience of pain

Factors influencing pain perception

• Personality:• Introvert: greater sensitivity, fewer

complaints• Extrovert: High pain tolerance• Psychological factors• Religion• Response of healthcare staff• Sleep deprivation• Society

Barriers influencing pain assessment

• Clinician influenced• Insufficient knowledge• Lack of pain training in medical school• Lack of pain-assessment skills• Rigidity or timidity in prescribing

practices• Overestimation of risks involved in the

therapy

Barriers influencing pain assessment

• Patient influenced• Reluctance to report pain• Reluctance to take opioid drugs• Poor adherence to management plan• Healthcare system influenced• Low priority given to symptom control• Unavailability or bureaucracy in opioid

analgesic administration• Inaccesibility of specialised care

Objectives of pain assessment

• To make a working diagnosis define the extent of injury or disease

• To determine the type of pain• To establish co-existing medical,

emotional and psychological factors influencing pain

(soldiers and sportsmen can sustain severephysical trauma without initially feeling pain)

Objectives of pain assessment

• To determine a pain management strategy on the basis of information obtained

• To evaluate response to therapy• To compare and monitor progress of

individual patients• To validate effectiveness of new

treatments for clinical and research purposes

Pain history

• First- hand history from the patient• Pain description: a verbal picture of pain• Primary or secondary complaint• Location and radiation• Specific site of pain• Mode of onset• Intensity and severity• Character

Pain history• Temporal features• Exacerbating and relieving factors• Associated symptoms• How pain has changed since onset• Treatments so far• Medical aspects• Functional status• Psychological assessment• Factors relevant to treatment

Physical Examination

• Inspection: Attention to symmetry and cutaneous landmarks

• Skin colour, rashes, scars, abnormal hair growth, pseudomotor dysfunction, oedema, muscular atrophy, hypertrophy or fasciculations, spinal curvatures, limb lengths

Physical Examination• Palpation: Perform in a systematic and

comprehensive manner from the least painful to the most painful area helps differentiate normal tissues and painful region

• Elicits gross sensory changes: allodynia, dysaesthesia,paraesthesia, hyper/hypoalgesia, hyperpathia, hypoaesthesia and analgesia dolorosa

• Elicits painful muscle bands or nodules, (tender/trigger points), neuromas in scars, peripheral pulsations and temperature

• Percussion: can indicate nerve entrapment or presence of a neuroma (Tinel’s sign). Percussion of bony structures may indicate fracture, dislocation, inflammation, infection

• Range of motion: for articulated areas, active and passive range of motion, all movements possible for that particular joint and their effect on pain in degrees

• Motor examination: Muscle bulk, tone, isolated muscle power, involuntary movements should be assessed and correlated with myotomal innervations

Physical Examination• Sensory examination: response to light

touch, light pressure, pinprick or cold and vibration

• Match any sensory changes to dermatomal and peripheral cutaneous nerve maps to assess the anatomical significance

• Reflexes: tendon reflexes are increased in upper motor neurone lesions and decreased in lower motor neurone lesions and muscular diseases

• Provocative tests: concordant vs non-concordant pain

• Phalen’s sign: carpal-tunnel’s syndrome• Patrick/Faber (Flexion ABduction External

Rotation): for hip pathologies• Sciatic and femoral nerve stretching tests• Straight leg raising test• Lasegue’s test: differentiate hamstring tightness

and spondylolisthesis• Crossed SLR• Bowstring test• Valsalva manoeuvre

radiological examinations;• Plain X-rays• MRI• fMRI• CT• SPECT scan• Others: thermography, diagnostic nerve blocks,

measurement of autonomic variables• These investigations are helpful to rule out

rather than diagnose the cause of pain

Investigations

Investigations Repetition of investigations will have

potentially negative effects on the patient’s expectations of management and be an unnecessary expense

Pain Measurement• The multidimensional nature of pain offers many

potential ‘targets’ for measurement.• Pain is a subjective, personal experience, the

logical and true assessments of a patient’s pain must be the patient’s own report. The self-report is the gold standard of pain measurement.

• Self report measurement tools: unidimensional (e.g. categorical scales, numerical rating scales (NRS), visual analogue scales (VAS), picture scales or pain drawings

• Multidimensional: e.g. McGill pain questionnaire

Pain Measurement• Categorical scales/verbal rating scales• Are you in Pain?-yes/no• none, mild, moderate,severe, excruciating• Pain relief: none, slightly, moderate, good,

complete• 0,1,2,3,4• Advantages: quick, simple,suitable for the

elderly,older children,visually impaired, sensitive to ethnic and gender differences

• Disadvantages: subject to bias

Pain Measurement• Visual analogue scales: 10 cm straight line,

scoring by measuring the distance in mm from left to right

no pain worst pain

imaginable

No pain relief complete pain relief

Pain Measurement• Advantages: quick, simple, avoidance of

imprecise, descriptive terms, suitable for children over 5 years, parametric statistical tests can be applied

• Disadvantages:more demanding, requires greater cognitive skills (concentration,language), may not be easy to measure extremes, can be influenced by medication, sleep disturbance, it measures relief better

Multidimensional Tools: • Classical Pain: three dimensions• sensory-discriminative• Motivational-affective• Cognitive-evaluative• Long-form McGill questionnaire• Short form of McGill pain questionnaire• Brief pain inventory• Health-related quality of life measures• Hospital anxiety and depression scale

OTHER TYPES OF PAIN• Post-operative Pain• Assessment of pain in children: • Physiological: heart rate, blood pressure,

respiratory rate, palmar sweating, transcutaneous oxygen, serum catecholamine, glucagon and cortisol

• Behavioural: crying, grimacing, irritability• Self-report measures: faces

scale,VAS,CHEOPS,FLACC(face-legs-activity-cry-consolability)

• Pain in the elderly: be aware of dementia, confusion and cognitive deficit,deafness

KEY POINTS• Pain assessment is multidimensional

including biological, psychological and social elements

• A thorough history is required along with what the pain means to the patient

• Patient expectations must be assessed before a management plan is produced

• Many scoring systems exist for scoring pain and are validated in a variety of clinical and research settings

KEY POINTS• Patient self-reports of pain and direct

involvement in assessment is the gold standard. Observational reporting and proxy reporting are less reliable

• Pain should be considered as the 5th vital sign with documentation showing the intensity, action taken and response to intervention

• Many pain scales are (e.g. VAS,VSR,NRS) easy to use in the clinical setting

DIFFERENCES BETWEEN ACUTE AND CHRONIC PAIN

Acute Pain Chronic pain

<3 months duration >3 months duration

Protective, preventing further damage Prevents normal functioning

Useful Not useful

e.g. broken limb, appendicitis e.g. post-herpetic neuralgia,

chronic low back pain

Risk factors for developing chronic low back pain and long-term disability• Belief that pain and activity are harmful• Sickness behaviors such as extended rest• Social withdrawal• Emotional problems such as low or negative

mood, depression, anxiety or stress• Problems and/or dissatisfaction at work• Problems with claims or compensation or time off

work• Overprotective family; lack of support• Inappropriate expectations of treatment

Classification of the sensory component of chronic pain

Nociceptive Non-nociceptive

Visceral Somatic Neuropathic Idiopathic

Nociceptive pain

• is presumed to be maintained by continual tissue injury

• Somatic pain: Arises in tissues such as joints, bones and muscles and is well localised.

• e.g:arthritic pain• described as aching, stabbing or

throbbing

Nociceptive pain• Visceral pain: Arises from viscera in the

thorax, abdomen or pelvis.• tends to be rather diffuse and poorly

defined and may be described as deep, dull or colicky

• referred to other locations• e.g: chronic refractory angina• associated with motor reflexes such as

muscle spasms and with autonomic reflexes such as nausea and vomiting

Non-nociceptive pain• Neuropathic pain: is due to injury to the

nociceptive pathway, either peripherally or centrally

• e.g: post-herpetic neuralgia is peripheral• e.g: post-stroke pain is central• described as burning or ‘electric shock-like’• clinical features: allodynia, hyperalgesia and

hyperpathia• Idiopathic pain: No identifiable organic cause• e.g: atypical facial pain

Emotional Components of Chronic Pain

Thoughts

Physical sensation Feelings

Behaviours

Management of chronic pain• Analgesics• Adjunct analgesics• Neurostimulation techniques• Topical treatments• Injections• Neurolytic therapies• Improving and optimising the patient’s

level of functioning: improving sleep, graded exercise programme, treatment of anxiety and depression

KEY POINTS• The clinician has to understand the sensory

and emotional components of chronic pain• The clinician has to be aware of treatments

available for pain• Most importantly, the clinician has to

understand the patient• Psychosocial factors are more important

than medical factors in the development of disability

• Being off work with chronic pain for more than 6 months means the chance of returning to work is only 50%, after 1 year off work it is only 10%

• The emotional aspects must not be underestimated as there is wide variation in the reported severity of pain experienced by individuals in association with comparable noxious stimuli

• Improvements in how a patient manages their chronic pain can be very rewarding for the healthcare professionals involved

THE WHO ANALGESIC LADDER

Weak opioids(eg.Codeine) ±Non-opioids ±Adjuvants

Strong opioids (eg. morphine ±non-opioids ±adjuvants

Non-opioids (e.g paracetamol,NSAIDS) ±Adjuvants

Pain controlled

Pain persisting or increasing

Routes of administration of analgesics

• Route Comments• Oral: Ideal for chronic use, dependent on

patient’s ability to swallow, gastric emptying,food and pH, opioids have low oral bioavailability

• Intramuscular: Pain and tissue irritation on injection, unreliable plasma concentration especially in low perfusion, unsuitable for long term use

Routes of administration of analgesics

• Intravenous rapid action, can be titrated to effectHigh bioavailability,

not dependent on patients characteristics unsuitable for long term use• Subcutaneous absorption is variable and

dependent on tissue perfusionused for long term opioid administration

especially in malignancy related pain• Transmucosal sublingual, buccal, and gingival modes of

administrationOffers rapid onset and patient comfort, oral transmucosalfentanyl citrate-for breakthrough cancer pain

Routes of administration of analgesics

• Rectal: Unreliable absorption and mucosal irritation• Transdermal: Improved patient compliance, long duration of

action and steady plasma concentrations, slow onset makes it less useful for acute pain, Fentanyl and buprenorphine patches are popular in chronic pain management

• Topical: Topical NSAIDS are effective in acute pain• Intraarticular: Not popular, intra-articular morphine provides

good analgesia following arthroscopies; steroid injections are used in treating arthritis

• Inhalational: Limited use, inhaled entonox (50% nitrous oxide+50% oxygen) is used for labour analgesia and change of dressing in burns

Side Effects of Analgesics

Class Complications

NSAIDS Gastrointestinal ulceration/bleeding, impaired platelet function, fluid retention, reduction in renal blood flow, bronchospasm, Reye’s syndrome and anaphlaxis

Opioids Respiratory depression, nausea and vomiting, constipation, euphoria/dysphoria

EDUCATION IN MEDICATION USE

• First session: • Introduction to drugs• Types of medicines• Benefits, uses, side-effects and problems.• Second session:• Tolerance• Addiction and dependence• Physical and psychological dependence• Withdrawal: problems and benefits• Monitoring medicines• When to use painkillers

MEDICATION• Non-steroidal anti-inflammatory drugs

(NSAIDS)• Opioids and opioid-containing medicines

including co-compounds• Paracetamol• Tranquillisers (benzodiazepines)• Anti-depressants (tricyclic antidepressants,

newer antidepressants, selective serotonin uptake inhibitors (SSRIs)

• Anticonvulsants• Others

PRINCIPLES OF DRUG WITHDRAWAL• Choose to reduce or withdraw from one drug at

a time• Choose the easiest one first (probably the

opioid)• Start by stabilising level of medication usage• Change from pain-contingent to time-

contingent medication• Keep timing of medication the same (do not

extend time between medication)• Reduce the amount taken by a small amount

(half a tablet) at a time• Reward success

PSYCHOLOGICAL COMPONENT• General guidelines for teaching relaxation

exercises:• Adress posture and find a comfortable position• Begin with abdominal breathing• Wear loose, comfortable clothing• Importance of scheduling,space and time (aim

to be undisturbed for 30’ min)• Anticipate ‘unsuccessful sessions and don’t

lose confidence or become dishearted• Develop a relaxed approach rather than simply

applying a technique

Ways of implementing relaxation skills:

• normal relaxation:15-30 min, once a day• Brief relaxation: 5-10 min, several times a

day, in any position• Mini relaxation: few seconds to few

minutes, anytime, often,identify ‘trouble spots’ for muscular tension

Key facets of sleep hygiene:• Avoid stimulants such as caffeine,smoking,

alcohol and proprietary painkilling or cold remedies, which contain stimulants particularly late in the day

• Avoid excessive intake of liquid for some hours before sleep

• Timetable analgesic medication appropriately• Stay in bed only when asleep and restrict the

time in bed if not sleeping

Key facets of sleep hygiene

• Get up and go to another room and read or perform routine tasks until feeling sleepy then return to bed

• Only use the bed for sleep (or physical intimacy)

THANK YOU FOR YOUR ATTENTION