Indications and Procedures (Magill’s Medical Guide, Sixth Edition)
Pain is experienced as an unpleasant reaction to either an external stimulus (such as a burn) or an internal process (such as a disease). The initial evaluation of pain is aimed at determining the cause. A good description by the patient aids diagnosis. The person experiencing the pain must be able to communicate the intensity, location, pattern (such as throbbing, steady, intermittent) and type (crushing, burning, sharp, or dull). In addition, factors that make the pain better or worse must be known and communicated. Duration is important; recent onset is termed “acute” pain while long-standing pain or pain that returns periodically is termed “chronic.”
Generally, the best way to treat pain is to prevent its occurrence. Failing that, a number of different interventions should be used together. Whatever treatment is used, the therapy must be tailored both to the patient and to the nature and severity of the pain. When medications are used, review of some important principles is essential, such as the pharmacology, duration of effectiveness, and optimal dose of a certain medication. Even the route of administration must be considered in every case.
Treatment may include combinations of simple analgesics, narcotics, and other treatments. Combinations take advantage of the additive pain relief while sparing the patient potential side effects. When choosing pain medications, a stepwise approach is often...
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For Further Information: (Magill’s Medical Guide, Sixth Edition)
Cousins, Michael J., and P. O. Bridenbaugh, eds. Cousins and Bridenbaugh’s Neural Blockade in Clinical Anesthesia and Management of Pain. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2009.
Dillard, James M. The Chronic Pain Solution: The Comprehensive, Step-by-Step Guide to Choosing the Best of Alternative and Conventional Medicine. New York: Bantam Books, 2002.
Ferrari, Lynne R., ed. Anesthesia and Pain Management for the Pediatrician. Baltimore: Johns Hopkins University Press, 1999.
Ferrer-Brechner, Theresa. Common Problems in Pain Management. Chicago: Year Book Medical, 1990.
Fishman, Scott, with Lisa Berger. The War on Pain: How Breakthroughs in the New Field of Pain Medicine Are Turning the Tide Against Suffering. New York: HarperCollins, 2001.
Loeser, John D., ed. Bonica’s Management of Pain. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2010.
Raj, Prithvi, and Lee Ann Paradise, eds. Pain Medicine: A Comprehensive Review. 2d ed. St. Louis, Mo.: Mosby, 2003.
Rosenfeld, Arthur. The Truth About Chronic Pain: Patients and Professionals on How to Face It, Understand It, Overcome It. Rev. ed. New York: Basic Books, 2005.
(The entire section is 165 words.)
Introduction (Psychology and Mental Health)
Contemporary attempts to define pain specify the inclusion of both physiological and psychological components. That is, at least in higher species, pain is not simply a function of bodily damage alone. The amount and quality of pain are also influenced by a number of psychological factors. These include the focus of one’s attention, one’s thoughts concerning the pain (including one’s understanding of its consequences), one’s culture, and the degree to which one feels that one can, at least partially, control the pain. These elements, originating from the cortex, thalamus, and limbic system, modulate pain in the body via descending neural tracts in the spinal cord.
The interaction of psychology and physiology is demonstrated by the phenomenon of stress-induced analgesia. Stress brought on by swimming in cold water, by running a marathon, or perhaps by being wounded in battle results in the production of the body’s own chemical pain suppressors, the endorphins (endogenous morphines), to help suppress the pain.
The influence of psychological factors on pain is also demonstrated in research on the effects of placebos. Although not all people respond to placebos, about one-third do obtain relief comparable to the effects of the drug presumed to be administered. Research has shown that the pain suppression effect of a placebo is influenced by several factors. These include the assumed strength of the drug being...
(The entire section is 867 words.)
Pain Management Techniques (Psychology and Mental Health)
Several techniques have been found to be effective for the management of acute or recurring pain. Two of these are hypnosis and biofeedback.
Hypnosis has been found to be effective as the sole or supplementary anesthetic for a variety of painful procedures, including tooth extractions, surgery, and childbirth. Two important factors influencing the effectiveness of hypnosis in pain relief are the patient’s ability to be hypnotized and the therapist’s ability to elicit responses appropriate and adequate to bring about useful perceptual alterations. According to Josephine Hilgard, the best candidates for hypnosis are those people who have a rich imagination, enjoy daydreaming, and can generate vivid mental images. Hypnotic management of pain includes specific suggestions of dissociation (reducing emotional involvement), distraction, changing interpretation of body signals, displacing pain to a different body part, or suggestions of numbness.
Psychologists have used biofeedback to help people control recurrent pain. The object of this technique is for the person to learn to use higher mental processes to regulate physiological functioning. To do this, the person must learn to discriminate subtle internal cues associated with desired physiological changes and reproduce these cues at will. Biofeedback also facilitates the learning of relaxation, which may reduce chronic pain involving muscle contraction....
(The entire section is 390 words.)
Behavioral Approaches (Psychology and Mental Health)
Psychological approaches have also been adapted to help people deal with chronic pain. These include operant and cognitive behavioral approaches.
The object of the operant approach is to reduce the excessive disability associated with the pain problem, rather than to reduce the pain itself. The first step in this procedure is one of confrontation and education, that is, to convince the person that he or she can do more even if the pain continues. Typically, it is the family that serves as the primary reinforcer of disability and activity. Therefore, their cooperation and involvement are essential if this approach is to be effective in the long term. The most common reinforcers used in the treatment are praise and attention. Rest may also be used as a reinforcer following the completion of activities. Undesirable behaviors, such as talking about the pain or screaming, are not rewarded with attention. Desired behaviors are broken down into small increments. The pain patient is encouraged to do more and more over time. This gradually results in the person being able to engage in more normal activities. As activity increases, there is a progressive withdrawal from pain medications.
The focus of the cognitive behavioral approach is to convince the person that the pain is at least partially under his or her control. The person is provided with a range of coping skills to help deal with maladaptive thoughts and noxious...
(The entire section is 446 words.)
Pharmaceutical Treatments (Psychology and Mental Health)
Medications are used to augment psychological management strategies. Over-the-counter nonsteroidal anti-inflammatory drugs such as acetaminophen, aspirin, and stronger prescription drugs like them are the most widely used pain medications. The World Health Organization recommends that they be used throughout a pain treatment. For more severe pain, such as cancer pain, long-acting opiate drugs, such as oxycodone, morphine sulfate, and methadone, are added. Shorter-acting opiates are then added for pain that “breaks through” this core treatment.
Antidepressant drugs are commonly used to treat pain. Since the 1960’s, tricyclic antidepressants such as amitriptyline and imipramine have been shown to be beneficial adjuvants to a pain treatment. These medicines act on noradrenergic pathways. Serotonin reuptake inhibitor drugs, such as paroxetine and citalopram, are effective for pain because of their action on serotonin receptors in inflamed tissue, the descending serotonergic tract of the spinal cord, and the serotonergic neurons that modulate opiate pathways in the periaqueductal gray. Many other types of medicine, acting on the multiple systems that modulate pain, are also used in pain control.
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Necessity of Pain Research (Psychology and Mental Health)
With the exception of a very few individuals, every person occasionally experiences acute pain. This may be the result of a toothache, cuts or bruises received while engaging in an athletic event, or countless other sources of injury. In addition, tens of millions of people in the United States, and probably hundreds of millions of people around the world, suffer from the effects of chronic pain, lower-back pain, arthritis, and various forms of headache. Migraine headaches alone are thought to cost up to seventeen billion dollars in lost productivity annually. In addition to the financial costs, untreated pain has a host of negative health consequences, including lower immune function, increased tumor growth, and the health consequences of self-medication through substance abuse.
Despite these deleterious effects, pain remains an underrecognized and undertreated social problem. On medical wards, up to half of patients suffer with untreated pain. Reasons include patient stoicism and fears of addiction, and doctors’ lack of pain management training. Although studies have repeatedly shown that pain treatment does not lead to addiction, fears persist. Psychological methods of pain control can help lessen fears of dependency on medication and enhance appropriate medication use.
Pain management is a truly interdisciplinary concern. Future development will be dependent on the cooperation of people in the fields...
(The entire section is 256 words.)
Sources for Further Study (Psychology and Mental Health)
Barber, Joseph, and Cheri Adrian, eds. Psychological Approaches to the Management of Pain. New York: Brunner/Mazel, 1982. A compilation of selections, written by authorities from both research and applied areas, concerned with psychology of pain control. Major topics include the use of hypnosis (including self-hypnosis) for the control of pain, the management of acute pain, and the treatments used in interdisciplinary pain clinics.
Benzon, Honororio T., James P. Rathmell, Christopher L. Wu, et al. Raj’s Practical Management of Pain. 4th ed. Philadelphia: Mosby-Elsevier, 2008. Although designed for the medical professional, this resource contains information on treating a variety of conditions, including orofacial pain, phantom pain, postoperative pain, and AIDS.
Bresler, David E., and Richard Trubo. Free Yourself from Pain. New York: Awareness Press, 1999. Discusses the nature and control of pain, as well as a number of both traditional and unconventional therapies used in pain management. Numerous self-help forms are included.
Hiesiger, Emile, and Kathleen Brady. Your Pain Is Real: Free Yourself from Chronic Pain with Breakthrough Medical Discoveries. New York: HarperCollins, 2002. Neurologist and pain management specialist Hiesiger seeks to empower the chronic pain sufferer. Similar in content to The Pain Relief Handbook but more recent.
(The entire section is 280 words.)
Pain Management (Encyclopedia of Cancer)
Pain management in cancer care encompasses all the actions taken to keep people with cancer as free of pain as possible. It includes pharmacological, psychological, and spiritual approaches to prevent, reduce, or stop pain sensations.
It is estimated that more than 800,000 new cases of cancer are diagnosed each year in the United States, and 430,000 cancer victims will die. Though recent figures are hopeful and suggest a decline in both the incidence of cancer and the number of people who die from it, studies have consistently shown that at least 70% of cancer patients in the advanced stage of the disease will experience significant pain. Pain is a localized sensation ranging from mild discomfort to an unbearable, excruciating experience. It is, in its origins, a protective mechanism, designed to alert the brain to injury or disease conditions. Unfortunately, when the cause of the pain is known, such as in diagnosed cancer, and treatment is initiated, pain can often continue.
Once the message of cancer has been received and interpreted by the brain, further pain can be counter-productive. Pain can have a negative impact on a person's quality of life, causing depression and impeding...
(The entire section is 2822 words.)
Pain Management (Encyclopedia of Medicine)
Pain management encompasses pharmacological, nonpharmacological, and other approaches to prevent, reduce, or stop pain sensations.
Pain serves as an alert to potential or actual damage to the body. The definition for damage is quite broad; pain can arise from injury as well as disease. After the message is received and interpreted, further pain can be counter-productive. Pain can have a negative impact on a person's quality of life and impede recovery from illness or injury. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person's health and outlook. Managing pain properly facilitates recovery, prevents additional health complications, and improves an individual's quality of life.
What is pain?
Before considering pain management, a review of pain definitions and mechanisms may be useful. Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. PNS includes all nerves throughout the body except the brain and spinal cord.
A pain message is...
(The entire section is 2544 words.)
Pain Management (Encyclopedia of Surgery)
If pain can be defined as a highly unpleasant, individualized experience of one of the body's defense mechanisms indicating an injury or problem, pain management encompasses all interventions used to understand and ease pain, and, if possible, to alleviate the cause of the pain.
Pain serves to alert a person to potential or actual damage to the body. The definition for damage is quite broad: pain can arise from injury as well as disease. After the message is received and interpreted, further pain can be counterproductive. Pain can have a negative impact on a person's quality of life and impede recovery from illness or injury, thus contributing to escalating health care costs. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person's health and outlook. Managing pain properly facilitates recovery, prevents additional health complications, and improves an individual's quality of life.
Yet, the experiencing of pain is a completely unique occurrence for each person, a complex combination of several factors other than the pain itself. It is influenced by:
- Ethnic and cultural values. In some cultures, tolerating pain is related to showing strength and...
(The entire section is 3360 words.)
Pain Management (Encyclopedia of Children's Health)
Pain management covers a number of methods to prevent, reduce, or stop pain sensations. These include the use of medications; physical methods such as ice and physical therapy; and psychological methods.
Pain serves as an alert to potential or actual damage to the body. The definition for damage is quite broad; pain can arise from injury as well as disease. Pain that acts as a warning is called productive pain. After the message is received and interpreted, further pain offers no real benefit. Pain can have a negative impact on a person's quality of life and impede recovery from illness or injury. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person's health and outlook. Managing pain properly facilitates recovery, prevents additional health complications, and improves a person's quality of life.
For many years it was believed that infants do not feel pain the way older children and adults do. As of the early 2000s, however, there has been a better understanding of the problems of pain, even in infancy.
Before considering pain management, a review of pain...
(The entire section is 2450 words.)
Pain Management (Encyclopedia of Nursing & Allied Health)
If pain can be defined as a highly unpleasant, individualized experience of one of the body's defense mechanisms indicating an injury or problem, pain management encompasses all interventions used to understand and ease pain, and, if possible, to alleviate the cause of the pain.
Pain serves to alert us to potential or actual damage to the body. The definition for damage is quite broad; pain can arise from injury as well as disease. After the message is received and interpreted, further pain can be counter-productive. Pain can have a negative impact on a person's quality of life and impede recovery from illness or injury, thus contributing to escalating health care costs. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person's health and out-look. Managing pain properly facilitates recovery, prevents additional health complications, and improves an individual's quality of life.
Yet the experiencing of pain is a completely unique occurrence for each person, a complex combination of several factors other than the pain itself. It is influenced by:
- Ethnic and cultural values. In some cultures tolerating pain is related to showing strength and endurance. In others, it is considered punishment for misdeeds.
- Age. The concept that grownups don't cry.
- Anxiety and stress related to being in a strange, fearful place such as a hospital, fear of the unknown consequences of the pain and the condition causing it can all make pain feel more severe.
- Fatigue and depression. It is known that pain in itself can actually cause depression. Fatigue from lack of sleep or the illness itself also contribute to depressed feelings.
As noted, the perception of pain is an individual experience. Health care providers play an important role in understanding their patients' pain. All too often, both physicians and nurses have been found to incorrectly assess the severity of pain. A study reported in the Journal of Advanced Nursing evaluated nurses' perceptions of a select group of American-born and Mexican-American women patients' pain following gallbladder surgery. Objective assessments of each patient's pain showed little difference between the severity for each group. Yet nurses involved in the study consistently rated all patients' pain as less than the patients reported, and with equal consistency, believed that better-educated women born in the United States were suffering more than less educated, Mexican-American women. Nurses from a Northern European background were more apt to minimize the severity of pain than nurses from Eastern and Southern Europe or Africa. Health care staff, and especially nursing staff, need to be aware of how their own background and experience contributes to how they perceive a person's pain.
Before considering pain management, a review of pain definitions and mechanisms may be useful. Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. PNS includes all nerves throughout the body except the brain and spinal cord. Pain is sometimes categorized by its site of origin, either cutaneous (originating in the skin of subcutaneous tissue, such as a shaving nick or paper cut), deep somatic pain (arising from bone, ligaments and tendons, nerves, or veins and arteries), or visceral (appearing as a result of stimulation of pain receptor nerves around organs such as the brain, lungs, or those in the abdomen).
A pain message is transmitted to the CNS by special PNS nerve cells called nociceptors. Nociceptors are distributed throughout the body and respond to different stimuli depending on their location. For example, nociceptors that extend from the skin are stimulated by sensations such as pressure, temperature, and chemical changes.
When a nociceptor is stimulated, neurotransmitters are released within the cell. Neurotransmitters are chemicals found within the nervous system that facilitate nerve cell communication. The nociceptor transmits its signal to nerve cells within the spinal cord, which conveys the pain message to the thalamus, a specific region in the brain.
Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural painkillers, called endorphins, to derail further pain messages from the same source. However, these natural painkillers may not adequately dampen a continuing pain message. Also, depending on how the brain has processed the pain information, certain hormones, such as prostaglandins, may be released. These hormones enhance the pain message and play a role in immune system responses to injury, such as inflammation. Certain neurotransmitters, especially substance P and calcitonin gene-related peptide, actively enhance the pain message at the injury site and within the spinal cord.
Pain is generally divided into two additional categories, acute and chronic. Nociceptive pain, or the pain that is transmitted by nociceptors, is typically called acute pain. This kind of pain is associated with injury, headaches, disease, and many other conditions. Response to acute pain is made by the sympathetic nervous system (the nerves responsible for the fight or flight response of the body). It normally resolves once the condition that precipitated it is resolved.
Following some disorders, pain does not resolve. Even after healing or a cure has been achieved, the brain continues to perceive pain. In this situation, the pain may be considered chronic. Chronic pain is within the province of the parasympathetic nervous system, and the changeover occurs as the body attempts to adapt to the pain. The time limit used to define chronic pain typically ranges from three to six months, although some health-care professionals prefer a more flexible definition, and consider chronic pain as pain that endures beyond a normal healing time. The pain associated with cancer, persistent and degenerative conditions, and neuropathy, or nerve damage, is included in the chronic category. Also, unremitting pain that lacks an identifiable physical cause, such as the majority of cases of low back pain, may be considered chronic. The underlying biochemistry of chronic pain appears to be different from regular nociceptive pain.
It has been hypothesized that uninterrupted and unrelenting pain can induce changes in the spinal cord. In the past, severing a nerve's connection to the CNS has treated intractable pain. However, the lack of any sensory information being relayed by that nerve can cause pain transmission in the spinal cord to go into overdrive, as evidenced by the phantom limb pain experienced by amputees. Evidence is accumulating that unrelenting pain or the complete lack of nerve signals increases the
number of pain receptors in the spinal cord. Nerve cells in the spinal cord may also begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Immune chemicals, primarily cytokines, may play a prominent role in such changes.
Considering the different causes and types of pain, as well as its nature and intensity, management can require an interdisciplinary approach. The elements of this approach include treating the underlying cause of pain, pharmacological and nonpharmacological therapies, and some invasive (surgical) procedures.
Treating the cause of pain underpins the idea of managing it. Injuries are repaired, diseases are diagnosed, and certain encounters with pain can be anticipated and treated prophylactically (by prevention). However, there are no guarantees of immediate relief from pain. Recovery can be impeded by pain and quality of life can be damaged. Therefore, pharmacological and other therapies have developed over time to address these aspects of disease and injury.
PHARMACOLOGICAL OPTIONS. General guidelines developed by the World Health Organization (WHO) have been developed for pain management. These guidelines operate upon a three-step ladder approach:
- Mild pain is alleviated with acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs and acetaminophen are available as over-the-counter and prescription medications, and are frequently the initial pharmacological treatment for pain. These drugs can also be used as adjuncts to the other drug therapies that might require a doctor's prescription. NSAIDs include aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters, such as prostaglandins. Acetaminophen is also effective against pain, but its ability to reduce inflammation is limited. NSAIDs and acetaminophen are effective for most forms of acute (sharp, but of a short course) pain.
- Mild to moderate pain is eased with a milder opioid medication plus acetaminophen or NSAIDs. Opioids are both actual opiate drugs such as morphine and codeine, and synthetic drugs based on the structure of opium. This drug class includes drugs such as oxy-codon, methadone, and meperidine (Demerol). They provide pain relief by binding to specific opioid receptors in the brain and spinal cord.
- Moderate to severe pain is treated with stronger opioid drugs plus acetaminophen or NSAIDs. Morphine is sometimes referred to as the gold standard of palliative care as it is not expensive, can be given starting with smaller doses and gradually increased, and is highly effective over a long period of time. It can also be given by a number of different routes, including by mouth, rectally, or by injection.
Although antidepressant drugs were developed to treat depression, it has been discovered that they are also effective in combating chronic headaches, cancer pain, and pain associated with nerve damage. Antidepressants that have been shown to have analgesic (pain-reducing) properties include amitriptyline (Elavil), trazodone (Desyrel), and imipramine (Tofranil). Anticonvulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) and carbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.
Close monitoring of the effects of pain medications is required in order to assure that adequate amounts of medication are given to produce the desired pain relief. When a person is comfortable with a certain dosage of medication, oncologists typically convert to a long-acting version of that medication. Transdermal fentanyl patches (Duragesic) are a common example of a long-acting opioid drug often used for cancer pain management. A patch containing the drug is applied to the skin and continues to deliver the drug to the person for typically three days. Pumps are also available that provide an opioid medication upon demand when the person is experiencing pain. By pressing a button, they can release a set dose of medication into an intravenous solution or an implanted catheter. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug. Research is underway to develop toxic substances that act selectively on nerve cells that carry pain messages to the brain, killing these selected cells and thus stopping transmission of the pain message.
NONPHARMACOLOGICAL OPTIONS. Pain treatment options that do not use drugs are often used as adjuncts to, rather than replacements for, drug therapy. One of the benefits of non-drug therapies is that an individual can take a more active stance against pain. Relaxation techniques, such as yoga and meditation, are used to focus the brain elsewhere than on the pain, decrease muscle tension and reduce stress. Tension and stress can also be reduced through biofeedback, in which an individual consciously attempts to modify skin temperature, muscle tension, blood pressure, and heart rate.
Participating in normal activities and exercising can also help control pain levels. Through physical therapy, an individual learns beneficial exercises for reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body's natural pain killers.
Acupuncture involves the insertion of small needles into the skin at key points. Acupressure uses these same key points, but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged are very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupting pain signals and inducing release of endorphins. To be effective, use of TENS should be medically supervised.
INVASIVE PROCEDURES. There are three types of invasive procedures that may be used to manage or treat pain: anatomic, augmentative, and ablative. These procedures involve surgery, and certain guidelines should be followed before carrying out a procedure with permanent effects. First, the cause of the pain must be clearly identified. Next, surgery should be done only if noninvasive procedures are ineffective. Third, any psychological issues should be addressed. Finally, there should be a reasonable expectation of success.
Anatomic procedures involve correcting the injury or removing the cause of pain. Relatively common anatomic procedures are decompression surgeries, such as repairing a herniated disk in the lower back or relieving the nerve compression related to carpal tunnel syndrome. Another anatomic procedure is neurolysis, also called a nerve block, which involves destroying a portion of a peripheral nerve.
Augmentative procedures include electrical stimulation or direct application of drugs to the nerves that are transmitting the pain signals. Electrical stimulation works on the same principle as TENS. In this procedure, instead of applying the current across the skin, electrodes are implanted to stimulate peripheral nerves or nerves in the spinal cord. Augmentative procedures also include implanted drug-delivery systems. In these systems, catheters are implanted in the spine to allow direct delivery of drugs to the CNS.
Ablative procedures are characterized by severing a nerve and disconnecting it from the CNS. However, this method may not address potential alterations within the spinal cord. These changes perpetuate pain messages and do not cease even when the connection between the sensory nerve and the CNS is severed. With growing understanding of neuropathic pain and development of less invasive procedures, ablative procedures are used less frequently. However, they do have applications in select cases of peripheral neuropathy, cancer pain, and other disorders.
Prior to beginning management, pain is thoroughly evaluated. Pain scales or questionnaires are used to attach an objective measure to a subjective experience. Objective measurements allow health care workers a better understanding of the pain being suffered by the patient.
Acuteeferring to pain in response to injury or other stimulus that resolves when the injury heals or the stimulus is removed.
Chroniceferring to pain that endures beyond the term of an injury or painful stimulus. Can also refer to cancer pain, pain from a chronic or degenerative disease, and pain from an unidentified cause.
CNS or central nervous systemhe part of the nervous system that includes the brain and the spinal cord.
Iatrogenicesulting from the activity of the physician.
Neurotransmitterhemicals within the nervous system that transmit information from or between nerve cells.
Nociceptor nerve cell that is capable of sensing pain and transmitting a pain signal.
Nonpharmacologicaleferring to therapy that does not involve drugs.
Parasympathetic nervous systemertaining to that part of the autonomic nervous system consisting of nerves that arise from the cranial and sacral regions and which oppose the action of the sympathetic nervous system.
Pharmacologicaleferring to therapy that relies on drugs.
PNS or peripheral nervous systemerves that are outside of the brain and spinal cord.
Stimulus factor capable of eliciting a response in a nerve.
Sympathetic nervous systemhe portion of the autonomic nervous system consisting of nerves that originate in the thoracic and lumbar spinal cord and that function in opposition to the parasympathetic nervous system.
Evaluation also includes physical examinations and diagnostic tests to determine underlying causes. Some evaluations require assessments from several viewpoints, including neurology, psychiatry and psychology, and physical therapy. If pain is due to a medical procedure, management consists of anticipating the type and intensity of associated pain and managing it preemptively.
Nurses or physicians often take what is called a pain history. This will help to provide important information that can help health care providers to better manage the patient's pain. A typical pain history includes the following questions:
- Where is the pain located?
- On a scale of 1 to 10, with 1 meaning the least pain, how would the person rate the pain they are experiencing?
- Describe what the pain feels like.
- When did (or does) the pain start?
- How long has the person had it?
- Is the person sometimes free of pain?
- Does the person know of anything that triggers the pain, or makes it worse?
- Does the person have other symptoms (nausea, dizziness, blurred vision, etc.) during or after the pain?
- What pain medications or other measures has the person found to help in easing the pain?
- How does the pain affect the person's ability to carry on normal activities?
- What does it mean to the person that they are experiencing pain?
An assessment by nursing staff as well as other health care providers should be made to determine the effectiveness of the pain management interventions employed. There are objective, measurable signs and symptoms of pain that can be looked for. The goal of good pain management is the absence of these signs:
Signs of acute pain:
- rise in pulse and blood pressure
- more rapid breathing
- perspiring profusely, clammy skin
- taut muscles
- more tense appearance, fast speech, very alert
- unusually pale skin
- pupils of the eye are dilated
Signs of chronic pain:
- lower pulse and blood pressure
- changeable breathing pattern
- skin is warm and dry
- nausea and vomiting
- slow speech in monotone
- inability, or difficulty in getting out of bed and doing activities
- pupils of the eye are constricted
When these signs are absent and the patient appears to be comfortable, health care providers can consider their interventions to have been successful. It is also important to document interventions used, and what ones were successful.
Owing to toxicity over the long term, some drugs can only be used for acute pain or as adjuncts in chronic pain management. NSAIDs have the well-known side effect of causing gastrointestinal bleeding, and long-term use of acetaminophen has been linked to kidney and liver damage. Other drugs, especially narcotics, have serious side effects, such as constipation, drowsiness, and nausea. Serious side effects can also accompany pharmacological therapies; mood swings, confusion, bone thinning, cataract formation, increased blood pressure, and other problems may discourage or prevent use of some analgesics.
Nonpharmacological therapies carry little or no risks. However, it is advised that individuals recovering from serious illness or injury consult with their health care providers or physical therapists before making use of adjunct therapies. Invasive procedures carry risks similar to other surgical procedures, such as infection, reaction to anesthesia, iatrogenic (injury as a result of treatment) injury, and failure.
A traditional concern about narcotics use has been the risk of promoting addiction. As narcotic use continues over time, the body becomes accustomed to the drug and adjusts normal functions to accommodate to its presence. Therefore, to elicit the same level of action, it is necessary to increase dosage over time. As dosage increases, an individual may become physically dependent on narcotic drugs.
However, physical dependence is different from psychological addiction. Physical dependence is characterized by discomfort if drug administration suddenly stops, while psychological addiction is characterized by an overpowering craving for the drug for reasons other than pain relief. Psychological addiction is a very real and necessary concern in some instances, but it should not interfere with a genuine need for narcotic pain relief. However, caution must be taken with people with a history of addictive behavior.
Effective application of pain management techniques reduces or eliminates acute or chronic pain. This treatment can improve an individual's quality of life and aid in recovery from injury and disease.
Health care team roles
Physicians, both primary care physicians (PCPs) and surgeons, treat both the conditions causing the pain, and the pain itself. The physician's role as teacher is an important one, alleviating fears about both the patient's condition and the possibility of addiction to narcotics, which is often a fear among patients on narcotic medication. Some physicians specialize in the treatment of pain, and work out of pain clinics.
Registered nurses (RNs) are the professional staff member that will likely spend the most time with the patient, whether the patient is in the hospital or other health care facility, or at home. Gathering the necessary information regarding the person's pain through a pain history, and careful observation and listening can help tremendously in the provision of pain relief. RNs also administer the medications at times, and provide information to the patient about the various medications that may be used, and allay concerns about the use of them.
Licensed practical nurses (LPNs) also spend considerable time with the patient in a health care facility or at home. Like RNs, LPNs administer medications as necessary, and provide information to patients.
Pain clinic staff may be any of the above, or psychologists, social workers, occupational or recreational therapists, or other people with specific training in group therapy, yoga, meditation, or other non-pharmacological means of relieving pain.
Pharmacists fill prescriptions for pain-relieving medications, monitor the use of narcotic medications, and provide information regarding the uses and side-effects of the medications.
Kozier, Barbara, RN, MN, Glenora Erb, RN, BSN, Kathleen Blais, RN, EdD, and Judith M. Wilkinson, RNC, MA, MS. Fundamentals of Nursing, Concepts, Process and Practice. 5th ed. Redwood City, CA: Addison-Wesley, 1995.
Salerno, Evelyn, and Joyce S. Willens, eds. Pain Management Handbook: An Interdisciplinary Approach. St. Louis: Mosby, 1996.
American Chronic Pain Association. P.O. Box 850, Rocklin, CA 95677-0850. (916) 632-0922. <<a href="http://members.tripod.com/~widdy/acpa.html">http://members.tripod.com/~widdy/acpa.html>.
American Pain Society. 4700 West Lake Ave., Glenview, IL 60025. (847) 375-4715. <<a href="http://www.ampainsoc.org">http://www.ampainsoc.org>.
National Chronic Pain Outreach Association, Inc. P.O. Box 274, Millboro, VA 24460-9606. (540) 597-5004.
What We Know About Pain. National Institute of Dental Research, National Institute of Health, Bethseda, MD20892. (301) 496-4261.
Joan M. Schonbeck