Pain Management

For Nursing students Level-III

By Mr. Takele D.(BSc, MPH)

 What is pain?
Definition
• “Pain is a more terrible lord of mankind than even death
itself” Albert Schweitzer
• The International Association for Study of Pain (IASP) defines
• pain as an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage. This highlights that:-
• pain is not just a physical sensation but an emotional
experience too.
• In simple words pain is what the patient says, hurts, which
gives emphasis on the patient’s experience.
Section A: Causes of Pain, Assessment and
Treatment
• The concept of total pain, refers to the global
nature of pain perception not only as a
physical ailment but that it has a
psychological, spiritual and social
consequences.
The concept of Total Pain (first described by
Cecily Saunders)
Cause and classifications of pain
• Though pain sensation, perception and interpretation is a complex
phenomenon, here is the simplified explanation.
• A noxious stimulus stimulates the bare nerve endings (the
nociceptors) and the impulse is transmitted to the dorsal horn, then
to the thalamus and cortex resulting in appreciation of pain. This
mechanism accounts for most of the pain stimuli.
• Pain is always subjective and the perception of pain may be modified
by problems or influences related to any, or all, of the potential
causes of suffering.
• The experience of pain depends also upon the patient’s mood,
morale and the meaning of the pain for the individual.
• Pain is classified as acute vs chronic and nociceptive vs neuropathic.
 2.2.1-Acute versus chronic pain
• Acute pain is due to a definable acute disease
or injury, duration limited to healing of tissue
in days or weeks,
• accompanied by anxiety and sympathetic
over-activity (sweating, tachycardia,
tachypnea etc.).
• It has the physiologic purpose of protecting
the body from further injury or facilitating
healing.
 …Classification of pain
Chronic pain
• persists months beyond the usual course of an
acute disease reasonable time for an injury to heal,
• associated with a chronic pathological process
which causes continuous pain or pain which recurs
at intervals for months or years.
• It is accompanied by psychological problems such
as depression but
• no sympathetic response due to adaptation of the
sympathetic nervous system.
2.2.2-Neuropathic versus Nociceptive Pain
• Neuropathic pain is caused by damage to the central or
peripheral nervous system.
• Neuropathic pain can be caused by injury, compression or
infiltration of a nerve.
• Examples include :post herpetic neuralgia or sciatic pain
resulting from prolapsed intervertebral disc.
• Injured nerves react abnormally to stimuli or discharge
spontaneously as they become hyper-excitable.
• Often neuropathic pain is described as a burning, tingling
or stinging sensation or a shooting electric shock-like
sensation – ‘pins and needles’.
 nociceptive pain
• nociceptive pain arises from noxious stimuli,
potential or actual injury of somatic or
visceral tissues of the body.
 Assessment of Pain
• Pain should be considered as the 5th vital sign.
• A proper assessment of pain is essential for
successful treatment.
• Patients often have more than one type of pain.
• Some may be unrelated to or only indirectly
related to the primary disease and they would
need different modalities of treatment.
The initial assessment involves the following:-
• detailed history taking including psychosocial
assessment,
• physical assessment, and
• diagnostic evaluation.
• In palliative care there are many different possible
causes of pain.
• It is important to establish the cause of pain.
• Therapy should be directed at the cause wherever
possible.
• The best approach to differentiate cause and origin is to
attempt to characterize pain through the well-known
pneumonic “P Q R S T”.
• P -refers to Precipitating and palliating (relieving) factors,
• Q -refers to Quality of pain (e.g. burning, stabbing,
throbbing, aching, stinging)
• R -Radiation of pain
• S -Site(document on body diagram) and
• T -Timing (duration of pain, recurrence, whether constant
or intermittent) and Treatment (the effect of current and
previous medications)
• In palliative care it is not only sufficient to characterize the pain
but also measure the degree of severity as objectively as possible.
• To assess success of treatment some form of quantization of pain
is necessary.
• The simplest and most reliable index of pain is the patient’s verbal
report.
• For regular follow-up, it will be useful to grade the pain at every
visit on a pain scale.
• Many pain-scoring systems (pain scales) are available, but
• The numerical scale of ten is the most recommended in adults
while
• The facial scale is effective in pediatric age.
 Scales
• Categorical or verbal rating scale: - A four or five point scale could
grade the pain as none, mild, moderate, severe and excruciating etc.
This scale is simple to apply but is not sensitive enough.
• Numerical Scale: - It has 0 at one end meaning no pain and 10 at the
other end meaning worst imaginable pain
• (No pain ) 0 1 2 3 4 5 6 7 8 9 10 (Worst possible pain)
• Visual Analogue Scale (VAS): - A100 mm scale with no pain at one end
worst imaginable pain at the other is particularly used in clinical trials,
as it is more amenable to statistical analysis than numerical scale. It is
a simple line on which the patient marks X to denote how strong their
pain is
• No pain Worst possible pain
• 4- Palms Pain Scale or Five-finger score (0-5) Figure 1- Five-finger score
 Show on your fingers how severe is pain
….5 is most severe
• The hand scale
• The hand scale ranges from a clenched hand (which represents ‘No hurt’) to five
extended digits (which represents ‘Hurts worst’), with each extended digit indicating
increasing levels of pain. Note: it is important to explain this to the patient as a
closed fist could be interpreted as worst possible pain in some cultures.
• 5- For children: The Faces pain scale Figure 2- The Faces pain scale for children
• (The Faces pain scale has been revised so that the scale is from zero to ten).
• Use with children who can talk (usually 3 years and older)
• Explain to the child that each face is for a person who feels happy because he has no
pain, or a little sad because he has a little pain, or very sad because he has a lot of
pain
• Ask the child to pick one face that best describes his or her current pain intensity
• Record the number of the pain level that the child reports to make treatment
decisions, follow-up, and compare between examinations
• For use in children less than three years of age or older non-verbal children FLACC
Scale is used to assess pain. See Annex 1.
Principles of chronic pain management
• The management of chronic pain involves the use of oral drug therapy by
the clock depending on the duration of action of the drug.
• Pain should be treated whenever possible, consider pharmacologic
precautions for all analgesic drugs as indicated in the annex.
• ‘By the mouth’:The oral route is best for the management of chronic pain.
• Oral medications should only be abandoned if the patient is unable to
take or retain them.
• ‘By the clock’: Analgesics should be given ‘by the clock’, i.e. at regular
intervals.
• Analgesics are given according to a strict schedule determined by the
duration of action, in order to prevent recurrence of pain.
• A patient on a regular schedule of analgesia will also need to have
available a ‘breakthrough’ dose for any episodes of breakthrough pain.
• ‘By the ladder’: the two/three step analgesic ladder (two step for
pediatric, three step for adults) which is meant for mild, moderate
and severe pain is to be followed.
• Unless the patient is in severe pain, begin by prescribing a non-
opioid drug and adjust the dose, if necessary, to the maximum
recommended dose.
• ‘For the individual’: the right dose of an analgesic is the dose that
relieves the pain.
• ‘Attention to detail’: it is essential to monitor the patient’s response
to the treatment to ensure that the patient obtains maximum
benefit with as few adverse effects as possible
• ‘Combination therapy using two or more analgesia of different
mechanism of action is evidence-based practice.
The WHO 3-Step Analgesic Ladder for Adults
 WHO 3-step analgesic ladder
• If pain is not controlled on Step 1 analgesics, a weak opioid (step 2) can be
added.
• If a weak opioid has been used to a maximum dose and the patient still has
pain, then move to Step 3.
• If a weak opioid is no longer effective on optimal dose, it is important not to
switch to another weak opioid on the same step of the ladder.
• A combination of a non-opioid and an opioid drug is effective in that the
different drugs have different mechanisms of action and they potentiate
each-others’ actions .
• If the patient still experiences pain on optimal dosage of Step 2 drugs, a
strong opioid is prescribed and the weak opioid stopped.
• Morphine oral solution or immediate release morphine is usually prescribed
as the initial strong opioid of choice when commencing Step 3, as it is a
quick-acting but short-acting drug, hence rapidly effective yet safe.
• Morphine oral solution is titrated against the patient’s pain
levels until pain is relieved, many patients who are well
controlled on morphine solution can continue to use this as
pain relief throughout their illness.
• If the patient’s pain improves they can also ‘step down’ the
analgesic ladder and use a weaker medication.
• It is often necessary and beneficial to continue with Step 1
analgesic even when a patient is on Step 3 but do not combine
Step 2 and Step 3 analgesics as their effect is produced by
binding to the same receptors.
• In effect the Step 2 analgesic may potentially block the effect
of the Step 3 analgesic.
• Another group of analgesia are referred to as adjuvants.
• This include tricyclic antidepressants (e.g. - Amitriptyline),
Anticonvulsants (Carbamazepine, Phenytoin), and steroids.
• These can be used alone or as first line choice in
neuropathic type of pain syndromes or in combination with
the above step 1, 2, and 3 analgesia in which case treatment
has failed and there is only a suspicion of neuropathy.
• Step I-Non opioid analgesia
• NSAIDs: They have a key role in the management of pain
associated with inflammation as in soft tissue infiltration
and bone metastases.
• NSAIDs differ in their effect on platelet function.
• Aspirin causes irreversible platelet inhibition whereas
Ibuprofen, etc. causes reversible platelet inhibition.
• Diclofenac etc. do not have any commendable effect on
platelet function.
• The dosage schedule for commonly used NSAIDs is:
• Diclofenac- 50mg bid,
• Ibuprofen- 400-600mg tid,
• Naproxen- 250-500mg bid,
• Indomethacin 25mg tid, and
• Aspirin 500-1000mg qid.
Common adverse effects of NSAIDs are:-
 gastric erosion,
 peptic ulcer and hemorrhage,
 Impaired renal and platelet function
 salt and water retention and
 bronchospasm.
• It is advised to avoid using aspirin in children and adolescents
under 16 yrs because of increased risk of Reye syndrome with
exception of idiopathic rheumatoid arthritis and rheumatic fever.
• Paracetamol: This is most available and least expensive over the
counter analgesia.
• Paracetamol is an antipyretic analgesic which inhibits
Cyclooxygenase in the central nervous system.
• It has a peripheral analgesic effect but lacks anti-
inflammatory effect. Its side effects are far less than
NSAIDS.
• The main drawbacks are the frequency of
administration (500-1000mg qid) - maximum dose
4gm/day.
• In pediatrics age maximum 4doses/day and its
potential for renal and hepatotoxicity.
 Step II –Weak Opioids
• Codeine3: The classic weak opioids are codeine and division of
opioids into weak and strong is to a certain extent arbitrary.
• Their affinity for the receptor is mild to moderate.
• Codeine is about 1/10 as potent as morphine and is more
constipating than other weak opioids.
• It is the pro-drug of morphine and used as analgesic,
antitussive and anti-diarrheal agent.
• An important rule is ‘not to change or jump from weak opioid
to another weak opioid’.
• Dose is 30-60mg q4h (10mg and 30mg tablets are available)
Maximum dose is 240mg.
• Tramadol: This is on the other hand is a synthetic weak opioid
analogue of complex structure and available without much
restriction.
• It is an alternative opioid for step 2.
• These are: action on opioid receptors and pre-synaptic re-uptake
blocker of nor adrenaline and serotonin.
• It can lower seizure threshold and therefore generally not
prescribed in patients with history of epilepsy.
• It is 1/5th to 1/10th as potent as morphine when taken orally and
through injection respectively.
• Dose: 50-100mg q8h-q6h. Maximum dose is 400mg.
• Weak opioids are not recommended for pediatrics age group
 Step III- Strong Opioids
• Morphine is the strong opioid of choice for the management of patients
with cancer and other illness who have moderate to severe pain.
• Strong opioids need to be given and their use is dictated by therapeutic
need and response, NOT by brevity of the prognosis.
• Morphine is available in different dosage formulation such as an aqueous
solution (5mg and 20mg/5ml), 10 mg tablets and parenteral preparation
which can be given IM, IV, and sc.
• In patients with hepatic and renal failure and among old aged groups,
care must be taken when prescribing and administering opioids.
• The correct dose is the one, which controls pain while causing minimum
side effects.
• The dose must be titrated for each individual patient starting from the
lowest possible dose in elderly and cachectic patients of 2.5mg/4hourly
to normal adults of 5mg/4hourly.
• There is no standard dose for morphine for the treatment of chronic
or cancer related pain and hence no ceiling effect, meaning dose is
escalated 72 hours and progressively until pain is controlled and side
effects such as nausea and drowsiness are tolerated.
• Always prescribe a laxative along with an opioid regularly as tolerance
is never developed for this particular, and, in selected patients an anti-
emetic on as required basis is prescribed if the risk of nausea and
vomiting is very disturbing.
• The latest FHMCA directive is that Codeine can be used in adults (not
pregnant and lactating women) on a case by case basis.
• Pharma covigilance is encouraged and any serious side effects should
be reported.
• Codeine should not be used in children.
• Another strong opioid is Fentanyl (see Annex 3 for special considerations when
prescribing pain medications).
• Normal release morphine (NR) is always started on four hourly basis and begins
to work after about 20 minutes and analgesia lasts four hours.
• In an opioid naïve patient, start with 2.5-5 mg morphine. Experienced Patients,
who are receiving an opioid, may require higher doses (based on equianalgesic
doses).
• It should be given four hourly.
• A double dose is given at bedtime and the midnight dose is skipped.
• A rescue dose is advised for breakthrough pain.
• This should be the same as the four hourly dose of morphine.
• If these breakthrough episodes persist and become more than 4 /day, dose
adjustment as above is required.
• The dose is increased by 30-50% every 3 days and it can also be reduced
progressively in the same manner
• Adverse effects: Even with the therapeutic dose of opioids the following
adverse effects are common.
• Constipation occurs in about 95% of patients and it may last as long as the
drug is continued.
• Constipation should be prevented rather than treated and co-
administration of a laxative is a must.
• Bisacodyl 5mg at night, increasing to 15mg if needed) unless the patient has
diarrhea.
• Nausea and vomiting occurs in 1/3rd of patients. It is usually seen in the first
few days of therapy and is usually self-limiting.
• Treat with Metoclopramide 10mg tid or Haloperidol 1.5mg once a day.
• Itching is also seen in less than 7% of the patients sometimes respond to 2-3
days of antihistamine therapy, use Chlorpheniramine.
• Other side effects include dry mouth, urinary hesitancy, and sleepiness.
Signs of toxicity:
• These appear when the administered dose of morphine is more
than what is required for pain relief, or when the pain is not
morphine-responsive, yet dose is escalated progressively.
• The signs are toxicity are delirium, myoclonus and drowsiness.
• Drowsiness occurs in up to 1/3rd of patients on initiation of
treatment or following a significant dose increase. If it persists
dose reduction is needed.
• Dose reduction is recommended in renal impairment and old age
and debility.
• These toxicities can be effectively managed with specific drugs
including naloxone, an opioid antagonist.
• As long as the dose escalation for morphine is made in a stepwise manner, there is less
likelihood of an excessive dose being given toxicities are unlikely to occur.
• But in situations such as renal failure there may be accumulations resulting in toxicities.
• There are reports where compulsive drug seeking behavior is exhibited by few patients who
have a past history of psychiatric illness.
• With the same token respiratory depression and addiction are NOT also problem with oral
morphine in patient with a clear indication.
• On the other hand, physical dependence is a normal physiological response to opioid
therapy, which causes withdrawal symptoms, if the drug is abruptly stopped or an opioid
antagonist is administered.
• Withdrawal symptoms can be effectively managed by gradual and supervised reduction of
the opioid therapy.
• Naloxone – reverses all opioid side effects, so both respiratory depression and pain relief are
reversed.
• Too much naloxone given too quickly and reversing analgesia may result in restlessness
hypertension and arrhythmias and has been known to precipitate cardiac arrest in a
sensitive patient.
• Indications for Naloxone
• RR < 8/minute.
• RR <12/minute, difficult to rouse, cyanosis
• RR < 12/minute, difficult to rouse, SaO2 <90%
• Dose: dilute naloxone 400 micrograms to 10ml with 0.9% saline. Give 0.5ml
(20 micrograms) IV every 2min until respiratory status is satisfactory. Further
boluses may be necessary because naloxone is shorter-acting than morphine.
• Note: There can be concerns when prescribing morphine that addiction can
occur. When used correctly, patients do not become dependent, tolerance is
uncommon and respiratory depression does not usually occur.
• The risk of addiction is commonly overestimated by patients and family, so it
is important for healthcare workers to alleviate their fears.
• When discontinuing morphine, avoid symptoms of withdrawal by titrating the
opioid dose down slowly.
WHO Analgesic Ladder for Children
• The two-step approach is an effective strategy for the pharmacological
management of persisting pain in children rather than the three-step
analgesic ladder used for adults.
• The three-step analgesic ladder recommends the use of codeine for
adults as a weak opioid for the treatment of moderate pain, while
• the two-step approach considers the use of low doses of strong opioid
analgesics for the treatment of moderate pain as the benefits of using
an effective strong opioid analgesic outweigh the benefits of
intermediate potency opioids in the pediatric population and
although recognized, the risks associated with strong opioids are
acceptable when compared with the uncertainty associated with the
response to codeine and tramadol in children.
The WHO 2-Step Analgesic Ladder for
Children
 Variation from the WHO pain management
protocol
• By mouth administration may not be feasible in dysphagia (sub-lingual or per-rectal or
parenteral administration)
• By the clock administration may not be possible as well in cases with renal failure and
dyspnea where the dose and frequency should be reduced or spaced. In renal failure,
morphine interval may need to be longer or the dose reduced. If no urine output, then
morphine should be stopped and given PRN.
• For breakthrough pain – the drug has to be given in between the specified intervals.
• In neonates – half life and clearance are variable
• A double dose is used at bed time to avoid waking the patient for medication
• By the ladder administration may be difficult in the following instances:
• ~ As in morphine trial for quick pain relief and for assessing the dose requirement
• ~Sticking to step 2 weak opioids when morphine is not available
• ~ Morphine may be used in smaller doses if step 2 are not available
• ~ Non opioid may be omitted for poor side effect profile
• ~Adjuvants may be omitted to minimize the number of drugs
• ~Go beyond step 3 in pain that is not responsive
 Adjuvant for pain
• The adjutants are not analgesics in the true pharmacological sense, but may contribute
significantly to pain relief whether used alone or in combination with the analgesics on the WHO
2/3-step ladder and they may have an analgesic sparing effect. Adjuvant analgesics are of
particular use in pain that is partially opioid-sensitive pain. Pain that is less sensitive to opioids
includes neuropathic pain, bone pain, pain associated with inflammation and sepsis. Pain
associated with smooth or skeletal muscle spasm will not respond to an opioid and will need an
adjuvant analgesic. Pain related to anxiety will also benefit from adjuvant analgesics.
• Anti-Depressants and Anti-Convulsants: Helpful for neuropathic pain, which may present as
burning, pricking, allodynia, paresthesia or sharp, shootingpain, e.g. Amitriptyline 25mgs at night.
Dose can be increased slowly up to 75mgs. Phenytoin: 100mgs bid, may increase slowly to
100mgs tid.
• Corticosteroids: are used as adjuvant treatment if neuropathic pain is suspected to be due to
nerve compression e.g. by tumor or inflammation (Betamethasone – 8mg daily or Prednisone 40-
60mg daily).
• Muscle relaxants/Anxiolytics: are used as an adjuvant for skeletal muscle spasm and anxiety-
related pain. For example: Diazepam. Adults. 5mg orally, 2-3 times per day.
• Antispasmodics:are helpful in relieving visceral distension pain and colic. E.g. Hyoscine
Butylbromide orally or subcutaneous.Dose: Adult: start at 10mg three times /day; can be
increased to 40mg three times/day
 Section B: Special considerations for HIV
and AIDS patients
• Pain in HIV and AIDS is highly prevalent, it has
various syndromal presentations, which can
result from two or three sources at a time and
has the potential of being poorly managed.
Such pain may be directly related to HIV
infection, immunosuppression or HIV therapy.
 Common sources of pain in HIV and AIDS
• Pharmacological pain management should be as per the WHO
analgesic ladder.
• NSAIDs, tricyclic antidepressants, anticonvulsants and non-
pharmacological interventions are important although NSAIDs could
exacerbate bone marrow disease and worsen the gastro-intestinal
effects of HIV and ARVs so should be used with caution.
• Many of the ARVs, especially the protease inhibitors, cause
abdominal discomfort, nausea and vomiting. Headache and
peripheral neuropathies are also common side effects of ART.
• Some antiretroviral medicines interact with analgesics and so caution
needs to be used when giving analgesics to patients on ART. The
main interactions occur with the adjuvant analgesics such as
phenytoin, carbamazepine, dexamethasone and amitriptyline.
 Section C: Non Pharmacological
management of pain
• Palliative care includes many non-pharmacological ways to manage ‘total’ pain. These therapies
address
• the physical, psychological, social and spiritual dimensions of pain.
• The following are a few holistic non pharmacological ways of treating pain. Anything that enhances
quality of life can, in turn, relieve pain.
• Listening and empathy
• Counseling – provides emotional support and practical suggestions
• Companionship and accompaniment – can help ease pain and increase comfort
• Activities such as favorite music, games, gardening, memory book – provides meaning and
distraction
• Spiritual/pastoral support and prayer – provides comfort, meaning and hope
• Positioning – enhances comfort and relieves pressure areas
• Bathing, grooming, and other care measures – enhances comfort and self-respect
• Exercise – improves mobility, circulation and skin integrity
• Massage, therapeutic touch
• Traditional therapies that are beneficial, healing and comforting
• Heat/cool applied locally – can reduce swelling and help relaxation
• Treatments such as radiotherapy can reduce inflammation, pain and tumor size.