Pain Management

PAIN MANAGEMENT  Negative sensation experienced by all human beings during the process of living.  Is a complex phenomenon derived from sensory stimuli or neurologic injury and modified by individual memory, expectations and emotions; usually associated w/ injury or a pathophysiologic process that causes an uncomfortable experience. PATHOPHYSIOLOGY of PAIN  Three major components of the Nervous system that cause the sensation and perception of pain are: 

Afferent Pathways (reception)

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Central Nervous System (perception)

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Efferent Pathways (reaction)

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Afferent pathways have nociceptors and are found on the skin

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Pacinian Corpuscles – nerve endings distributed in the skin– mediate sensation including pain, pressure and itch

 Free nerve endings of nociceptors – sensitive to mechanical, thermal, electrical, or chemical stimuli = responsible for transmitting sensory pain information 

Stimulation flows through peripheral sensory nerves (afferent pathways) to the spinal cord

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A painful stimulus (e.g., pinprick) sends an impulse to a nociceptor (a receptor for painful stimuli) along a

peripheral nerve fiber, which enters the gray matter of the spinal cord.  Nociceptors terminate in the SC 

Nociceptors stimulation flows to the brain through a series of relay neurons.

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When the pain stimulus or signal reaches the CNS – evaluated and interpreted in the limbic system, reticular formation, thalamus, hypothalamus, medulla and cerebral cortex.

The brain’s interpretation is based on both physical and psychologic aspects THE ART AND SCIENCE OF PAIN RELIEF  The goal of ideal pain mgt To relieve both acute and chronic pain with pharma and non-pharma techniques while minimizing side effects  responsible for the assessment of pain, administration of medications and assessment of effectiveness of pain mgt plan  greater reductions in the pain are seen when pharma and non-pharma techniques are combined PHARMACOLOGICAL MANAGEMENT (adjuvant drugs)  are not typically considered pain medicines but may relieve discomfort and potentiate the effect of pain meds to reduce side effect burden. 1. Antidepressants and anticonvulsant (tricyclics, SSRI, Carbamazepine,gabapentin)

-helpful for diabetic neuropathy, trigeminal neuralgia, postherpetic neuralgia 2. Topical analgesics (capsaicin, menthol methylsalicylate, EMLA cream, lidocaine gel) -helpful in chronic arthritis pain, herpes zoster and diabetic neuropathy; maybe used in painful procedures such as blood draws and venipuncture 3. Muscle relaxants (baclofen,diazepam) -muscle spasm 4. Antianxiety meds (diazepam,doxepin)-anxious or agitated 5. Meds to dry secretions (scopolamine,glycopyrrolate) - thick secretions that require frequent suctioning 6. Antipruritics (diphenhydramine, hydroxyzine) - sec to liver dse that are itchy and result in scratching 7. Diuretics (lasix) – ease discomfort from ascites from liver cancer or cirrhosis 8. Magic mouthwash (diphen elixir/Maalox/ lidocaine) – mucositis from chemo; add nystatin if w/ thrush PHARMACOLOGICAL PRINCIPLES FOR SUCCESSFUL PAIN MANAGEMENT

1. Pain meds given by mouth is the preferred way to control pain. It is the safest, least expensive and easiest route. 2. Works best when administered around the clock -long acting or sustained release forms for chronic pain conditions -immediate release or short acting breakthrough pain or pain associated with activity or procedures 3. Avoid the use of prn medications for pain control as the patient will learn to expect the return of pain - suffer psychologically and spiritually 4. Warn patients that crushing or chewing sustained release preparations of analgesics destroys their controlled release properties and cause rapid absorption resulting to overdosage NON PHARMACOLOGICAL METHODS TO MANAGE PAIN  Pain education program  Socialization or recreation program – movies, art therapy, therapeutic use of music  Modification of behaviour – imagery, hypnosis, relaxation  Physical Therapy – massage, ultrasound, exercise, hot and cold packs  Neurostimulation – acupuncture, TENS