Pain management

Dr Hicham Al Mawla
Er physician

Learning objectives
At the end of the workshop you will be able to:

Consider the important principles of pain and pain

management
Use validated tools to assist in assessing patients
pain
Outline strategies to manage pain with your
patients
Discuss pain medicines with your patients

What is pain?

An unpleasant sensory and

emotional experience associated

with actual or potential tissue
damage, or described in terms of
such damage.
International Association for the

Study of Pain (Merskey, 1979)

Pain is always subjective.

The patients self-report of pain is

the single most reliable indicator

of pain.
The clinician must accept the
patients self report of pain.

Types of pain
Acute pain can be important for the body to tell the brain

that there is something wrong and help to avoid harm.

Chronic pain is pain that goes on for a long time. It needs

regular assessment and a different approach to treatment.

Chronic pain impacts on the whole person

and their community
Ask your patients about

any changes that have

happened in their lives
since their ongoing pain
started.
For example:
How are you sleeping?
Are you feeling worried or

sad?
Are you still visiting friends
or relatives?
Are you eating well?

Things to talk about:

How pain is affecting their life

Where the pain is, how bad the pain is
How long they have had the pain
What medicines they are taking for the
pain (and any other conditions)
How the pain has affected them and
their family
If they have any other problems or
worries
Make sure people understand that it
may not be possible to be pain-free at
all times
Anticipation of pain

How do we assess pain

Ask the patient:
To describe their pain
Rate their pain (use the faces scale based on

how they perform everyday activities)

What made the pain worse or better
Observe the persons body language (how

freely do they move).

Talk with the person about how they feel,
and how it affects their everyday life
Talk with their family when appropriate
Make sure people understand that it may
not be possible to be pain-free at all times

REMINDER:
Use the same pain
assessment tool to keep a
detailed record of the
patients pain changes in the
clinic notes.

Managing chronic pain

Treatment goals:

To improve the level of activity

To modify thoughts about pain

and suffering
To promote self-management
To relieve pain to a tolerable
level

Managing chronic pain

Tips on helping people to

exercise
Educate patients that there is a
difference between hurt and
harm when you have chronic
pain. Avoiding physical activity
can make their pain seem worse
over time.
Encourage patients to talk to
their family and friends and not
isolate themselves. Also get a
family member or friend involved
as their exercise buddy.
You may wish to suggest some
exercises to try e.g. walking,
swimming, gentle stretching
exercises. Remember to start
slow with exercise as they may
feel some discomfort initially,
especially if they have been
inactive for a long time.

Medicines
Key points:
Use a step-wise approach

to introduce pain
medicines (analgesics)
Prescribe regular doses of
analgesics
Plan a trial period with
clear and specific
instructions
Review the effects on
regular basis eg may need
more frequent review for
new medicines or when
dose changes

Analgesics Non-opioid analgesics

AMH 2010, CARPA 5th edition

Nonsteroidal anti-inflammatory drugs

(NSAID)
Generic
names
and how
given
Other
NSAIDS

Diclofenac
Diclofenac Indomethacin Ketoprofen
Ketorolac Mefenamic acid Naproxen
Piroxicam Tiaprofenic acid
Cox-2 Inhibitors: Celecoxib Meloxicam
Parecoxib

What it
is used
for

Mild to moderate pain and fever

Reduces swelling and inflammation in
arthritis , period pain, sprains and injuries or
attacks of gout
Renal colic
Suppositories are used when the patient is
vomiting .They can still cause stomach pain
when used for long period s
Gels can be used as a rubbing medicine
Can be used with other medicines

How it
works

Prostaglandins in the body cause redness,

swelling and pain at the site of injury. NSAIDs
stop the body making prostaglandins

Adverse
effects
AMH 2010, CARPA 5th edition

Short-acting and long-acting opioids

Short-acting opioids

Long-acting opioids

codeine

Modifies release
tramadol

Tramadol

Methadone

hydromorphone

Modified-release
hydromorphone

Immediate-release
morphine
Immediate-release
oxycodone
Immediate-release
tramadol

Modified-release
morphine
Modified-release
oxycodone
Transdermal
buprenorphine

Opioid analgesics Combination analgesics

Generic
names
and
how
given

PARACETAMOL +
Codeine 30 mg

What it
is used
for

Moderate to strong pain relief

Can be used in combination with other pain
relief medicines

How it
works

Two different medicines work

together (but in different ways)
in the brain and nerve ending
to reduce pain

Adverse
effects

(Panadeine Forte , Codalgin

Forte )

Drink lots of water to prevent

constipation
Laxatives may be needed
Return to the clinic if need to
Use for more than a short time
If you take more than 8 tab lets a
day containing paracetamol you can
damage your liver (make sure there
is no paracetamol in your other
medicines)

Opioid analgesics - Morphine

AMH 2010, CARPA 5th edition

Opioid analgesics - Tramadol

Generic
names
and how
given

TRAMADOL

What it is
used for

Moderate to severe
pain
Slow release
formulations are
used for chronic pain

How it works

Adverse
effects

AMH 2010, CARPA 5th edition

Drug interactions (do not take

with) Warfarin SSRI Venlafaxine
Carbamazepine St Johns Wort

Acute vs. Chronic Pain Management

Acute Pain

Most often treated with:

NSAIDS
Opioids
Local anesthetics
Splinting
Positioning changes
Ice

Chronic
Pain
Most
often treated with:
Anti-seizure medications
Anti-depressant
medications
NSAIDS
Implantable devices
Psychological therapy
Acupuncture
When all else fails and
benefits outweigh risks
Opioids

Responsible Opioid
Prescribing
Assess risk for opioid abuse or diversion prior to

prescribing opioid.
Risk factors for misuse or abuse of opioids
include the following
Males between 18 and 45.
A personal history of substance abuse
A family history of substance abuse
A personal history of preadolescent sexual abuse
A personal history of psychological disease

(depression, anxiety, obsessive-compulsive

disorder

Take home messages

When you see a person who has
pain:
Perform a thorough history and physical

examination to determine if referral is necessary

Discuss options for managing pain with the

person
Recommend medicine only as part of an agreed

pain management plan