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Pain management ppt from Harrison for study purpose
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- 5. INTRODUCTION 1. Introduction Definition: Painis āan unpleasant sensory and emotional experienceā ā Associated with actual or potential tissue damage, or described in terms of such damageā ā¢ āPain is what the patient says hurtsā * Purpose of Pain: Acute ā acts as a protective signal; Chronic ā often becomes a maladaptive disease state . * Epidemiology: Affects millions worldwide, with chronic pain (>3 months) leading cause of disability .
- 6. CLASSIFICATION 2. Classification 1.ACUTE 2.SUBACUTE 3.CHRONIC a. Nonmalignant b.Malignant
- 7. CLASSIFICATION 2. Classification A. ByDuration (per Harrison & AMBOSS) TYPE Acute Subacute Chronic DURATION <1 Month 1-3 Months >3 Months ROLE Protective signal of tissue damage Transition phase Independent diseases; biopsychosocial
- 8. ACUTE PAIN ā¢ Injury,trauma, spasm or disease to skin, muscle, somatic structures or viscera; ā¢ Perceived and communicated via peripheral mechanisms (pathways) ā¢ Usually associated with autonomic response as well (tachycardia,Āblood pressure, diaphoresis, pallor, mydriasis (pupil dilation).
- 9. CHRONIC PAIN a.Non-malignant ā¢ Painpersists beyond the precipitating injury ā¢ Rarely accompanied by autonomic symptoms ā¢ Sufferers often fail to demonstrate objective evidence of underlying pathology. ā¢ Characterized by location-visceral, myofascial, or neurologic causes.
- 10. CHRONIC PAIN b.Malignant ā¢ Hascharacteristics of chronic pain as well as symptoms of acute pain (breakthrough pain). ā¢ Has a definable cause, e.g. tumour recurrence ā¢ In treatment, narcotic habituation is generally not a concern.
- 11. DIFFERENCE BETWEEN ACUTE& CHRONIC PAIN
- 12. CLASSIFICATION 2. Classification B. ByMechanism (Harrison & IASP-INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN) Nociceptive: Tissue injury ā superficial, deep, or visceral Neuropathic: Nerve damage ā peripheral (āburningā, ātinglingā) or central Nociplastic: Abnormal amplification without clear tissue damage
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- 14. Types of pain Basedon Mechanism (Harrison & IASP-INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN) 1.Nociceptive pain: Due to activation of nociceptors by tissue damage or inflammation * somatic pain: skin,bone,muscle (sharp well-localised) Example: Fracture, incision, arthritis * Visceral Pain: Internal organs (dull, poorly localized, cramping) Example: Appendicitis, gallstones, ischemia 2.Neuropathic pain: Caused by nerve damage (peripheral or central nervous system) * Peripheral: Diabetic neuropathy, trigeminal neuralgia *Central: Stroke, multiple sclerosis *Descriptors*: Burning, tingling, electric-shock-like 3. Nociplastic pain: Altered pain processing without clear tissue or nerve damage ā¢ Common in fibromyalgia, chronic tension headache, irritable bowel syndrome ā¢ Pain is widespread, variable, and not explained by structural damage
- 15. Types of pain Basedon duration A. By Duration (per Harrison & AMBOSS) TYPE Acute Subacute Chronic DURATION <1 Month 1-3 Months >3 Months DESCRIPTION Sudden onset, protective function, linked to injury Transition between acute and chronic Persistent, may become a disease in itself Examples of Chronic Pain: * Chronic back pain * Osteoarthritis * Phantom limb pain * Post-herpetic neuralgia
- 16. Types of pain Basedon causes (ICD-11) 1. Chronic Primary Pain * Pain is the disease itself * Includes: * Fibromyalgia * Chronic widespread pain * Non-specific low back pain 2. Chronic Secondary Pain * Pain is a symptom of another condition * Subtypes: * Cancer-related pain * Post-surgical/post-traumatic pain * Neuropathic pain * Visceral pain (IBD, endometriosis) * Musculoskeletal pain (RA, OA)
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- 18. Pain Assessment Pain History SOCRATES SITEOF PAIN- Somatic pain-well localized visceral pain-more diffuse(angina) ONSET- Speed of onset and any associations CHARACTERISTIC OF PAIN- Example: sharp,dull,burning,tingling,stabbing,crushing RADIATION OF PAIN ASSOCIATED SYMPTOMS TIME/DURIATION OF PAIN EXACERBATING FACTORS SEVERITY OF PAIN
- 19. Pain Assessment Pain History ā¢Other important additional questions to be asked. ā¢ What is the response to past and current analgesic therapy? ā¢ Any kind of diary or record about the pain? ā¢ Fears they have about analgesics?
- 20. Pain Assessment Pain assessmenttools Numeric rating scale Verbal descriptive Scales. Visual Analogue Scales. McGill pain questionnaire Factors to consider in choosing a pain scale 1. Age of patient 2. Physical condition 3. Level of consciousness 4. Mental status 5. Ability to communicate
- 21. Pain Assessment Numeric PainRating Scale ā¢ Ask the patient to rate their pain intensity on a scale of 0 (no pain) to 10 (the worst pain imaginable). ā¢ Some patients are unable to do this with only verbal instructions, but may be able to look at a number scale and point to the number that describes the intensity of pain
- 22. Pain Assessment ā¢ Wong-BakerFACES Pain Rating Scale ā¢ Can be used with young children (sometimes as young as 3 years of age) ā¢ Works well for many older children and adults as well as for those who speak a different language ā¢ Explain that each face represents a person who may have no pain, some pain, or as much pain as imaginable. Point to the appropriate face and say the appropriate description. e.g. āThis face hurts just a little bitā
- 23. Pain Assessment ā¢ Wong-BakerFACES Pain Rating Scale ā¢ Ask the patient to choose the face that best matches how she or he feels or how much they hurt.
- 24. Pain Assessment Color PainRating Scale ā¢ Ask the patient to point to the area on the scale that shows their level of pain from white (no pain) to dark red (worst possible pain). ā¢ Obtain a number corresponding to the area where the patient points.
- 25. Pain Assessment Severity Assessment ā¢McGill Pain Questionnaire ā¢ Scale from 0 to 5 ā¢ From None to Severe Pain ā¢ for children or adults who understand numerical relationships.
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- 28. Pain treatment Goals ofPain Management Therapy 1) Decreased pain 2) Decreased healthcare utilization o Decreased āshoppingā for care o Decreased emergency room visits 3) Improved functional status o Increased ability to perform activities of daily living o Return to employment
- 29. Pain treatment Management ā¢ Non-Pharamcologicaltreatment ā¢ Pharmacological treatment: ā¢ Analgesics ā¢ NSAIDs ā¢ Adjuvants ā¢ Others
- 30. Pain treatment Non-pharmacological interventions ā¢Exercise ā¢ Weight reduction ā¢ Counseling ā¢ Smoking cessation ā¢ Massage ,Relaxation therapy ā¢ Heat & cold applications
- 31. Pain treatment Pharmacological interventions Analgesics 1.Non opioid ā Analgesics (Step 1 WHO Ladder) Acetaminophen (Paracetamol) * Adults: 500ā1,000 mg PO every 6 hours, max 4 g/day. * Children: 15 mg/kg PO/PR q4ā6 h, max 60 mg/kg/day (max 4 g/day)
- 32. Pain treatment Pharmacological interventions Analgesics ā¢NSAIDs ā¢ 1. Ibuprofen 400ā800 mg PO every 6 hours (max 3,200 mg/day) . ā¢ 2. Diclofenac 50 mg PO q8 h or 75 mg PO bid (max 200 mg/day) . ā¢ 3. Ketorolac IV/IM 15ā30 mg q6 h (max 120 mg/day, ā¤ 5 days) ā¢ 4. Meloxicam 7.5ā15 mg PO q24 h ā¢ 5. Celecoxib 200 mg PO q12 h . ā¢ ā ļøUse NSAIDs cautiously with renal, cardiovascular, or GI comorbidities
- 33. Pain treatment Pharmacological interventions Analgesics 2.Weak Opioids (Step 2 WHO Ladder) Tramadol * Adults: 50ā100 mg PO every 4ā6 h PRN; max 400 mg/day . * Parenteral: 50ā100 mg IV/IM q4ā6 h PRN . Codeine combos * Codeine + Acetaminophen: 1ā2 tablets every 4 hours PRN (e.g., 30 mg codeine + 300 mg APAP) .
- 34. Pain treatment Pharmacological interventions Analgesics 3.Strong Opioids (Step 3 WHO Ladder) Morphine * Immediate-release: 10 mg PO q4 h PRN (typical replacement for IV dose ~0.1ā0.2 mg/kg IV q4 h) . * Modified-release: 10ā60 mg PO q12 h (dose-titrated) . * Injectable: 10 mg/mL ampules; IV dosing as above Oxycodone * Controlled-release: 10 mg PO q12 h
- 35. Pain treatment Pharmacological interventions Analgesics 3.Strong Opioids (Step 3 WHO Ladder) Fentanyl * Injectable: 0.35ā0.5 Āµg/kg IV every 30ā60 min PRN * Transdermal patch: used when oral intake not possible; dosing per product. Buprenorphine * Transdermal for chronic painādosing per product guidelines .
- 36. Pain treatment Pharmacological interventions Adjuvants 4.Adjuvants / Ancillaries * Antidepressants (e.g., amitriptyline, nortriptyline, SNRIs) for neuropathic pain. * Anticonvulsants (e.g., gabapentin/pregabalin). * Steroids, bisphosphonates, ziconotide (intrathecal) for specific cancer pain scenarios .
- 37. Pain treatment Pharmacological interventions 5.Special Populations * Children: Use age-appropriate preparations and weight-based dosing (e.g., ibuprofen 200 mg/5 mL syrup; paracetamol 120 mg/5 mL). * Elderly / Renal/Hepatic impairment: Start lower, titrate up cautiously for opioids and NSAIDs .
- 38. Pain treatment Choosing theAppropriate Analgesic ā¢ Match the severity of pain to the strength of the analgesic i.e. strong analgesics for severe pain. ā¢ The WHO has developed 3-step model to guide analgesic choice depending on the severity of the patientās pain.
- 39. Pain treatment WHO PainManagement Ladder ļ Step I: ļ§ NSAIDS Ā± adjuvants ļ Step II: ļ§ NSAID + Mild opioids Ā± adjuvant ļ Step III: ļ§ Strong opioids + NSAIDS Ā± adjuvants
- 40. Pain treatment Other modalities ā¢Nerve blocks, epidural blocks and ablative neurosurgical procedures may be effective in pain management. ā¢ Such procedures may be associated with return of pain after a number of months so that timing of procedures may be important.
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