2022 Pain

Clinically Relevant Features

• Presence of conditions or diseases that
require urgent evaluations

– Tumors, infection, fractures, neurological
damage

Clinically Relevant Features
This refers to clinical (i.e. physical) features that may alert to the presence of serious but
relatively uncommon conditions or diseases requiring urgent evaluation.
Such conditions include

tumors
infection
fractures
neurological damage.
Screening for serious conditions occurs as part of the history and physical examination
and should occur at the initial assessment and subsequent visits.

Related Behaviors

• Psychosocial and Occupational Factors

– Attitudes and beliefs about pain
– Behaviors
– Compensation issues
– Diagnostic and treatment issues
– Emotions
– Family
– Work

Related Behaviors
These terms were introduced to identify psychosocial and occupational factors that may
increase the risk of chronicity in people presenting with pain. The presence of such
factors is a prompt for further detailed assessment and early intervention. The areas to
evaluate include:

• attitudes and beliefs about pain
• behaviors
• compensation issues
• diagnostic and treatment issues
• emotions
• family
• work

PAIN MANAGEMENT

Pain Management

• people in pain want to:

– know what the problem is
– be reassured that it is not serious
– be relieved of their pain
– receive information.

Von Korff (1999) demonstrated that people in pain want to: know what the problem is;
be reassured that it is not serious; be relieved of their pain; and receive information.
People in pain want advice regarding the management of their pain, including non-
pharmacological and pharmacological interventions.
They also want advice on how to return to normal activity.
Patients may lack current knowledge of interventions for pain management. For
instance, they may believe that x-rays will determine the cause of their pain and that
bed rest is indicated.
It is important to satisfy the need for knowledge, alleviate fear and to focus on
preventing disability due to pain (Main 2002).
The use of a preventive approach to shape behavior is best done at the initial visit.

Pain Management Plan

• Tailored to meet the needs of each patient
• Designed to assist progress through an

episode of acute pain and the return to
normal function.
• Enable the individual to take responsibility
for his or her own rehabilitation
• There are three phases of the management
plan:

– Assessment
– Management
– Review

Pain Management Plan
The management plan should be tailored to meet the needs of each patient, taking their
preferences and abilities into account.

It is important to ensure that the patient understands what is involved to facilitate their
participation.

Management plans are designed to assist progress through an episode of acute pain
and the return to normal function.

The plan should include actions that the consumer and clinician may take in the event of
an exacerbation or recurrence of pain or slow progress to recovery.

The plan should enable the individual to take responsibility for his or her own
rehabilitation (bearing in mind that some people will require greater levels of support
and assistance) or to seek help from a clinician if necessary.

There are three phases of the management plan:
• Assessment
• Management
• Review

Assessment

• A history and physical examination are
conducted to assess whether clinical
features of serious conditions are present
and to identify psychosocial and occupational
factors that may influence recovery.

• Ancillary investigations for serious
conditions.

• In cases of serious conditions, an alternative
plan of management may be required.

Assessment
• A history and physical examination are conducted to assess whether clinical features
of serious conditions (‘red flags’) are present and to identify psychosocial and
occupational factors (‘yellow flags’) that may influence recovery.

• Ancillary investigations are not generally indicated unless features of serious
conditions are identified.

• In cases where features of serious conditions are present, an alternative plan of
management is required.

Management

• Provide Information
• Provide Assurance
• Provide advice to remain active
• Discuss treatment options

• Provide information — consumers seek an explanation and information about the
nature of their pain. The clinician should use effective communication techniques and
use appropriate terms to describe acute musculoskeletal pain.

• Provide assurance — the natural history of acute musculoskeletal pain is generally
favorable; thus, epidemiological data serves as the basis for assurance that recovery
can be expected. Information on the prognosis and the provision of assurance is an
integral part of the management plan.

• Provide advice to remain active — activity should be encouraged; resumption of
normal activity should occur as soon as possible. For each of the conditions covered by
these guidelines, activation is a seminal intervention for restoring function and avoiding
disability.

• Discuss other options for pain management including the addition of non-
pharmacological and pharmacological interventions to the management plan to assist
return to normal activity. A combination of measures may be used.

The clinician should provide information on the options available, what they are
designed to achieve and describe potential risks and benefits. It is important not to
overstate the power of interventions to avoid unrealistic expectations.

Review

• Prescription of a single, one-step
intervention is unlikely to be successful.

• Ongoing review provides an important
opportunity to assess for features of
serious conditions and psychosocial
factors

• Demonstrates concern that progress has
been made.

Review
• Prescription of a single, one-step intervention is unlikely to be successful.

The plan may be iterative, requiring small amendments or major changes.
On subsequent visits, the clinician should enquire whether the plan has been
satisfactory and explore questions, concerns and possible alternatives as
required. Further explanation and assurance can be provided.

• Ongoing review provides an important opportunity to assess for features of serious
conditions and psychosocial factors that may not have been evident on previous visits
and to intervene as required.

• Review also demonstrates concern that progress has been made. This is particularly
important when there was intense pain and distress at the initial presentation.

The need for further visits can be discussed at each consultation.

Interventions

• Intervention Strategies

– Non-pharmacological Interventions

• Active therapy
• Passive therapy
• Behavioral therapy

– Non-pharmacological interventions can be
used with pharmacological interventions

Interventions for Acute Pain
In addition to initial interventions such as providing information, assurance and advice to
maintain reasonable activity levels, other options (non-pharmacological and
pharmacological) exist for the management of acute musculoskeletal pain.

Non-pharmacological Interventions
Evidence for the effectiveness of a range of additional non-pharmacological (i.e. not
involving medication) interventions for people with acute musculoskeletal pain is
provided in the specific guideline topics.

These include active, passive and behavioral therapies.
Non-pharmacological interventions may be used in conjunction with
pharmacological interventions

Pharmacological Interventions

Acetylsalicylic (Aspirin)

Mechanism of Action
Like other non-steroidal anti-inflammatory drugs (NSAIDs),the action is believed to be due to the inhibition
of prostaglandin synthesis.

Therapeutic Use
Treatment of mild pain including, headache, arthralgia (joint pain) and myalgia (muscle pain). Treatment
of fever.

Absorption
Absorbed rapidly, partly from the stomach but mostly from the upper small intestine. Peak value in about
2 hours.

Metabolism
Rapidly metabolized in plasma into salicylic acid which is an active metabolite. Salicylic acid then
undergoes oxidation and conjugation with glucuronic acid and glycine in the liver.

Half-life
15-20 minutes.

Average Daily Dose (adult)
650 mg every four hours.

Adverse Effects
GI irritation and bleeding, aggravation of peptic ulcer, and Reye's Syndrome.

Drug Interaction
It can displace other drugs from plasma proteins such as sulfonamides. It may produce bleeding in
patients receiving anticoagulants.

Contraindication
Contraindicated in patients with chicken pox, peptic ulcer, hypersensitivity to aspirin, and/or in patients
with bleeding disorders.

Acetaminophen (Tylenol)

Mechanism of Action
Believed to be due to the inhibition of prostaglandin synthesis. However, unlike aspirin it does not exert
an anti-inflammatory effect.

Therapeutic Use
Mild pain and fever.

Absorption
Peak effect in 30-60 minutes. Rapidly absorbed in the gastrointestinal tract.

Metabolism
Primarily conjugated in the liver with glucuronic acid, sulfuric acid or cysteine. A small amount is
hydroxylated. A small portion undergoes cytochrome P-450 oxidation to form a toxic metabolite that can
damage the liver.

Half-life
2 Hours.

Average Daily Dose (adult)
1,000-3,000 mg. Should not exceed 4,000 mg.

Adverse Effects
The drug is usually well tolerated. Skin and other allergic reactions can occur, rarely. However, the main
toxicity with acetaminophen is the liver damage that can occur with large doses. Hepatotoxicity can result
from a single dose of 10-15 g. Higher doses can be fatal.

Drug Interaction
Chronic alcohol abusers may be at increased risk for liver toxicity.

Contraindication
Renal (kidney) insufficiency and anemia. Use with caution during pregnancy.

Ibuprofen (Motrin)

Mechanism of Action
Inhibits prostaglandin synthesis like other NSAIDS.

Therapeutic Use
Treatment of mild to moderate pain.

Absorption
Peak effect 1-2 hours. Well absorbed.

Metabolism
More than 90% of an ingested dose is excreted in the urine as metabolites.

Half-life
2 hours.

Average Daily Dose (adult)
400 mg three or four times a day.

Adverse Effects
Gastrointestinal disturbances, nausea, epigastric pain, heartburn and gastrointestinal bleeding.

Drug Interaction
Possible displacement of warfarin (coumadin) from plasma proteins to increase the toxicity of warfarin.

Contraindication
Should not be used in patients with hypersensitivity to Ibuprofen or other NSAIDs such as aspirin.

Darvocet

Mechanism of Action
Propoxyphene is a mild narcotic analgesic structurally related to methadone.

Therapeutic Use
Mild to moderate pain.

Absorption
Peak plasma concentrations are reached in 2-2 1/2 hours.

Metabolism
Metabolized in the liver by microsomal enzymes.

Half-life
6-12 hours.

Average Daily Dose (adult)
100 mg propoxyphene napsylate and 650 mg acetaminophen every 4 hours.

Adverse Effects
Dizziness, sedation, nausea and vomiting. Some of these adverse reactions may be alleviated if the
patient lies down.

Drug Interaction
The CNS-depressant effect of propoxyphene is additive with that of other CNS depressants, including
alcohol. Propoxyphene may slow the metabolism of a concomitantly administered drug.

Contraindication
Hypersensitivity to propoxyphene or acetaminophen.

Percodan

Mechanism of Action
The principal ingredient, oxycodone, is a semisynthetic narcotic analgesic with multiple actions
qualitatively similar to those of morphine; the most prominent of these involve the central nervous system
. Like other narcotic analgesics this drug acts by stimulating opioid receptors in the brain.

Therapeutic Use
Treatment of moderate to moderately severe pain.

Absorption
Readily absorbed from the gastrointestinal tract but is significantly metabolized by the liver before
reaching the systemic circulation.

Metabolism
Metabolized in the liver by P-450 enzymes. May also undergo glucuronic conjugation.

Half-life
Unknown.

Average Daily Dose (adult)
5-10 mg every 4-5 hours.

Adverse Effects
Lightheadedness, dizziness, sedation, nausea and vomiting.Can produce drug dependence.
Constipation. (See above for adverse effects of aspirin.)

Drug Interaction
CNS depressant effects may be additive with that of other CNS depressants. Aspirin may enhance the
effect of anticoagulants and inhibit the uricosuric effects of uricosuric agents.

Contraindication
Hypersensitivity to oxycodone or aspirin.

Hydrocodone & Acetaminophen
Vicodin

Mechanism of Action
Hydrocodone is a semisynthetic narcotic analgesic and antitussive with multiple actions qualitatively similar to those
of codeine. Same as other narcotic analgesics (see Oxycodone & Aspirin above).

Therapeutic Use
Treatment of moderate to moderately severe pain.

Absorption
Readily absorbed from the gastrointestinal tract but is significantly metabolized by the liver before reaching the
systemic circulation.

Metabolism
Metabolized in the liver by P-450 enzymes. May also undergo glucuronic conjugation.

Half-life
4 hours.

Average Daily Dose (adult)
One or two tablets every four to six hours as needed for pain.

Adverse Effects
May cause dependence due to narcotic ingredient. Lightheadedness, dizziness, sedation, nausea and vomiting.

Drug Interaction
Patients receiving other narcotic analgesics, antihistamines, antipsychotics, antianxiety agents or other CNS
depressants (including alcohol) concomitantly with Vicodin tablets may exhibit an additive CNS depression.

Contraindication
Contraindicated during lactation. Should not be administered to patients who have previously exhibited
hypersensitivity to hydrocodone or acetaminophen.

Sumatriptan (Imitrex)

Mechanism of Action
Has been demonstrated to be a selective agonist for a vascular 5-hydroxytryptamine receptor subtype.

Therapeutic Use
Acute migraine attacks with or without aura. Acute treatment of cluster headaches.

Absorption
Peak effect in about 2 hours after oral administration and 12 minutes after subcutaneous injection. Incomplete
absorption.

Metabolism
Metabolized by monoamine oxidase (MAO) to form indole acetic acid.

Half-life
2 1/2 hours.

Average Daily Dose (adult)
25 mg tablet taken with fluids; the maximum single dose recommended is 100 mg.

Adverse Effects
Tingling sensation, burning sensation, a feeling of warmth, a feeling of heaviness or pressure in the head. Some
patients experience tightness in the chest. Could precipitate a heart attack in susceptible individuals and therefore
should not be given to individuals with a history of ischemic heart disease or angina.

Drug Interaction
Imitrex tablets should not be used within 24 hours of an ergotamine-containing or ergot-type medication like
dihydroergotamine or methysergide.

Contraindication
Use with caution during lactation, in individuals with hepatic (liver) or renal (kidney) problems and in persons with
heart conditions. Any patients who are sensitive to sumatriptan.

Fiorinal

Mechanism of Action
Butalbital, aspirin and caffeine. Combines the analgesic properties of aspirin with the anxiolytic and
muscle relaxant properties of butalbital.

Therapeutic Use
Treatment of tension headaches.

Absorption
Well absorbed from the gastrointestinal tract. Peak blood levels are reached in 1 .5 hours.

Metabolism
Metabolized by the P-450 enzymes in the liver.

Half-life
Caffeine 4.9 hours. Aspirin, 15-20 minutes. Butalbital 35-88 hours.

Average Daily Dose (adult)
One or two tablets every 4 hours.

Adverse Effects
Drowsiness and dizziness. G.I. irritation for aspirin.

Drug Interaction
Alcohol and other CNS depressants may produce an additive CNS depression and should be avoided.

Contraindication
Patients with an aspirin allergy.

Behavioral Therapies

Psychological Interventions

• Adjunct to pharmacological and
rehabilitation modalities

• Grouped in categories:

– Information Provision
– Relaxation
– Attentional
– Hypnosis
– Cognitive-Behavioral

Psychological interventions used in the management of acute pain are generally seen
as adjuncts to pharmacological and physical therapeutic modalities, but there is growing
evidence for the value of their contribution.

Psychological interventions may be grouped into the following categories:
information provision (procedural or sensory);
relaxation and attentional strategies; and
hypnosis and cognitive-behavioral interventions.

Provision of Information

• Patient education

– Procedural
– Sensory

• Benefits varies according to patient

Provision of information
• Procedural information is information given to a patient before any treatment that
summarizes what will happen during that treatment.
• Sensory information is information that describes the sensory experiences the
patient may expect during the treatment.

The benefits or otherwise of providing procedural and/or sensory information may vary
according to patient group.

Provision of Information

• Combined Sensory-Procedural Information

– Reducing negative effects
– Limited studies on effect with post operative

pain relief

Provision of information
Combined sensory-procedural information is effective in reducing negative affect and
reports of procedure-related pain and distress in patients undergoing various diagnostic,
dental, experimental pain and other procedure.

Only a small number of studies included in this analysis investigated the effects in
patients having surgery where the combination led to improved pain relief and
postoperative activity.

However, results regarding the efficacy of the individual techniques are conflicting.
• In patients undergoing surgery, procedural information was reported to be
effective in reducing negative affect, pain report, pain medication use and
behavioral and clinical recovery while it is of no significant benefit after a
variety of mainly non-surgical procedures.
• In patients undergoing surgery the provision of sensory information has no
significant benefit, but it may have some, albeit inconsistent, value in other
procedures.
• In some patients, especially those with an avoidant coping style, providing too
much information or the need to make too many decisions may exacerbate
anxiety and pain although this may not be a strong effect.
• Nevertheless, it may be useful to assess a patient's normal approach to
managing stress (coping style) in order to identify the best options for that
patient.

Relaxation Strategies

• Relaxation

– Teaching patient to calm themselves

• Altering muscle tension
• Altering breathing patterns

– Similar to forms of meditation and self
hypnosis

• More research needed in this area

Relaxation and attentional strategies

Relaxation
Relaxation training usually involves teaching a patient ways to calm him/herself, either
by listening to a recorded audiotape or following written or spoken instructions, which
may then be memorized by the patient.
Some methods focus on altering muscle tension, often sequentially, while others
concentrate on altering breathing patterns.

Regardless of the approach used, repeated practice of the technique by the patient is
regarded as critical.

Relaxation techniques are closely related to, and often indistinguishable from, forms of
meditation and self-hypnosis.

The use of relaxation techniques in cancer patients undergoing acute medical treatment
was effective in reducing treatment-related pain as well as pulse rate, blood pressure
and emotional adjustment variables (depression, anxiety and hostility).

However, a systematic review of the use of relaxation techniques in the perioperative
setting, in which a lack of appropriate data meant that a meta-analysis was not
undertaken, showed that there is currently little convincing evidence of benefit.

Attentional Techniques

• Attentional Techniques

– Distraction
– Imagery
– Sensations (i.e., smells)

• Research inconclusive on efficacy of
attentional techniques

Attentional techniques
Attentional techniques aim to alter a patient’s attention in relation to their pain.

A range of such strategies have been reported from those involving distraction
using imaginary scenes or sensations, to those that focus on external stimuli
such as music, scenes or smells.
Some techniques also involve modification or re-interpretation of the experience
of pain (Logan et al 1995).

Attempting to alter the patient’s emotional state, from stress or fear to comfort or peace,
is also a common feature of many of these practices, which are often used in
conjunction with relaxation methods (Williams 1996).

In acute postoperative pain there is some evidence to support the use of some
attentional techniques, often in combination with relaxation, to reduce reported pain and
analgesic use (Daake & Gueldner 1989; Good et al 1999; Miro & Raich 1999; Voss et al
2004I).

Music does not reduce anxiety levels or pain in patients undergoing surgery or invasive
procedures (Evans 2002).

There is also some evidence to suggest that rather than shifting a patient’s attention
away from the pain, instructions to focus on the sensory rather than emotional stimuli
during a painful procedure can alter pain perception and reduce pain in patients
classified as having a high desire for control but low perceived control (Baron et al 1993;
Logan et al 1995).

Instructing patients to focus their attention on the pain site was more effective than
listening to music in reducing pain associated with burns dressing (Haythornthwaite et al
2001).

Hypnosis

• Hypnosis involves:

– Narrowing the focus of attention
– Reducing awareness of external stimuli
– Increased responsiveness to hypnotic

suggestions

• Research has proved efficacy of this
technique

Hypnosis
The essential components of hypnosis are considered to be a narrowed focus of
attention, reduced awareness of external stimuli, with absorption in and increased
responsiveness to “hypnotic suggestions” (Gamsa 2003).

The variable or unstandardized nature of hypnotic procedures makes it difficult to
compare studies or draw general conclusions about the effectiveness of the technique.

Hypnosis has been shown to provide effective relief of pain in both laboratory and
clinical settings (Montgomery et al 2000). Most of the studies using hypnosis for the
management of clinical acute pain have focused on acute procedural pain.

A review of the use of hypnosis in the management of clinical pain concluded that it was
effective in reducing acute pain associated with medical procedures, such as that during
burn wound care and bone marrow aspiration, and childbirth.

• In patients with cancer, hypnosis also reduces the pain associated with
procedures such as breast biopsy, lumbar puncture, and bone marrow aspiration.

• Hypnosis may be as effective as cognitive behavioral interventions in these
setting.

• Hypnosis used in labor leads to a decreased requirement for pharmacological
analgesia, increased incidence of spontaneous vaginal delivery and decreased
use of labor augmentation.

Cognitive-Behavioral

• Cognitive Behavioral Intervention

– Focus on overt behaviors and cognitions
(thought processes)

– Interactions between patient and others
(health care provider, family)

– Increases sense of control and decreases
sense of helplessness

Cognitive-behavioral interventions
Cognitive-behavioral interventions involve the application of principles derived from the
study of learning (or behavior change) and experimentally derived methods to change
the ways in which pain sufferers perceive and react to their pain (and other stressors)
(Bradley 1996).

Cognitive-behavioral interventions focus on overt behaviors and cognitions (thought
processes) in patients as well as on environmental contexts.

Interactions between the patient and others, especially health care providers and
family members, may need to be changed to support the desired response in the
patient.

These interventions may be helpful in promoting an increased sense of control
and reducing the sense of hopelessness and helplessness common among patients
with acute pain.

Critically, cognitive-behavioral principles require the patient to be an active participant in
the process, rather than a passive recipient. In addition to a technique like relaxation,
methods taught involve active problem-solving and addressing unhelpful beliefs and
responses.

Pain Coping Strategies

• Includes way to respond to pain

– Alarmists experience more pain and distress
– Coping strategies not effective in all

circumstances

• Used before a surgical procedure

– Improved pain experience, negative attitude
– Reduced pain meds

THIS ENDS THIS MODULE ON PAIN THEORY, ASSESSMENT,
INTERVENTION AND MANAGEMENT.