Pain Management

What is it?
Lisa M. Lackner, RN, MSN

Pain
What is the real definition of pain?
And what is pain management??
How can this information help me???

Pain
Definitions:
An unpleasant sensory and emotional experience
associated with actual or potential tissue damage.
Pain is whatever the experiencing person says it is.
May not be directly proportional to amount of tissue
injury.
Highly subjective, leading to undertreatment

Types of Pain
1. Acute
2. Cancer
3. Chronic non-malignant

Major Categories of Pain

Classified by inferred pathophysiology:

1. Nociceptive pain (stimuli from somatic

and visceral structures)
2. Neuropathic pain (stimuli abnormally
processed by the nervous system)

Anatomy and Physiology of

Nociceptive Pain
4 Basic Processes
Transductionnociceptors free nerve endings with the

capacity to distinguish between noxious and innocuous

stimuli. When exposed to mechanical (incision or
tumor growth), thermal (burn), or chemical (toxic
substance) stimuli, tissue damage occurs. Substances
are released by the damaged tissue which facilitates the
movement of pain impulse to the spinal cord.

Substances released
The substances released from the
traumatized tissue are:
prostaglandins
bradykinin
serotonin
substance P
histamine

So, for instance

Non-steroidal anti-inflammatories, such as
ibuprofen, are effective in minimizing pain
because they minimize the effects of these
substances released, especially
prostaglandins. Corticosteroids, such as
dexamethasone used for cancer pain, also
interferes with the production of
prostaglandins.

Transduction (cont.)
Sufficient amounts of noxious stimulation cause

the cell membrane of the neuron (nervous system

cell) to become permeable to sodium ions,
allowing the ions to rush into the cell and creating
a temporary positive charge. Then potassium
transfers back into the cell, thus changing the
charge back to a negative one. With this
depolariztion and repolarization, the noxious
stimuli is converted to an impulse. This impulse
takes just milliseconds to occur.

 Some analgesics relieve pain primarily by

decreasing the sodium and potassium
transfers at the neuron level, thereby
slowing or stopping pain transmission.
Exampleslocal anesthetics,
anticonvulsants used for neuropathic pain,
migraines.

Process #2Transmission
Impulse spinal cord brain stem
thalamus central structures of brain
pain is processed.
Neurotransmitters are needed to continue
the pain impulse from the spinal cord to the
brainopioids (narcotics) are effective
analgesics because they block the release of
neurotransmitters

Process #3Perception of Pain

The end result of the neural activity of pain
transmission
It is believed pain perception occurs in the cortical
structuresbehavioral strategies and therapy can
be applied to reduce pain. Brain can accommodate
a limited number of signalsdistraction, imagery,
relaxation signals may get through the gate,
leaving limited signals (such as pain) to be
transmitted to the higher structures.

Process #4Modulation of Pain

Changing or inhibiting pain impulses in the descending

tract (brain spinal cord)

Descending fibers also release substances such as
norepinephrine and serotonin (referred to as endogenous
opioids or endorphins) which have the capability of
inhibiting the transmission of noxious stimuli. Helps
explain wide variations of pain among people.
Cancer pain responds to antidepressants which interfere
with the reuptake of serotonin and norepinephrine which
increases their availability to inhibit noxious stimuli.

Pain

Neuropathic Pain
Abnormal processing of the impulses either by the
peripheral or central nervous system
May be caused by injury (amputation and
subsequent phantom limb pain), scar tissue from
surgery (back surgery high risk), nerve entrapment
(carpal tunnel), or damaged nerves (diabetic
neuropathy)
Unclear why depolarization and transmission of
pain impulse are spontaneous and repetitive

Pain Language
Acute pain: lasts less than 6 months, subsides
once the healing process is accomplished.

Chronic pain: involves complex processes and

pathology. Usually involves altered anatomy and
neural pathways. It is constant and prolonged,
lasting longer than 6 months, and sometimes, for
life.

more pain language

Narcoticobsolete term used to refer to what

is now called opioid. Current usage is
primarily in a legal context to refer to a
wide variety of substances of potential
abuse.

Pain
Amplifies the bodys stress response to
traumatic injury
Causes endocrine and metabolic
abnormalities
Impedes a patients recovery from trauma
and surgery

 Why treat pain?

Tissue damage has the potential to elicit
mechanisms that can create disabling,
refractory, chronic situations that may
prolong and even outlast the period of
healing.
Hedderich & Ness, 1999

Several Pain Theories

Theory #1
Cousins Theory of Pathophysiology of Acute Pain
Severe, unrelieved acute pain results in abnormally
enhanced physiological responses that lead to
pronounced and progressively increasing
pathophysiology
Pathophysiology significant organ dysfunction
morbidity and mortality

Harmful Effects
Cardiovascular and respiratory systems are
significantly affected by the
pathophysiology of pain
adrenergic stimulation
hypercoagulation, leading to DIC
heart rate
cardiac output
myocardial oxygen consumption

Pathophysiology of Pain (cont.)

pulmonary vital capacity
alveolar ventilation
functional residual capacity
arterial hypoxemia
suppression of immune functions,
predisposing trauma patients to wound
infections and sepsis

Theories of Pain #2
Selyes Theory of Stress and General Adaptation
Syndrome

During the initial assault (traumatic injury and

accompanying pain), a concentration of effort at

site of demand occurs.
Adaptive responses attempt to achieve
homeostasis
epinephrine and catecholamines released

The Stage of Alarm

The Stage of Resistance

(everything is being used up)
Energy
Nutrients
Oxygen

The Stage of Exhaustion

(homeostasis vs. death)
The body can no longer sustain its adaptive
responses
Devastating sequelae
Irreversible organ damage and death of the
patient

So what?
Trauma patients perceive pain as much of a
stressor as the injury itself and marshal the
same physiological responses

Pain can kill you

Theory #3
Neuman Systems Model

Individuals possess a unique central core of

survival factors
Individuals possess lines of defenses which
attempt to keep the individual in a steady
state

What influences lines of

resistance?
Past and present conditions of the individual
Available energy resources (pain consumes
energy)
Amount of energy required for adaptation
(remember Selyes theory of adaptation)
Patients perception of the stressor

Providing timely and effective pain

management to the injured patient can help
strengthen the patients lines of resistance

Neuman (continued)
If pain is allowed to be prolonged, the bodys
attempt to regain steady state may exhaust
the patients lines of resistance, leading to
disruption of the patients core structure
death may result.

Future Pain
Pain receptors in the periphery become more

sensitive after injury

Permanent changes can occur in spinal cord
pathways after even a brief exposure to severe,
unrelieved acute pain
Poorly controlled acute pain can predispose
patients to debilitating chronic pain syndromes
(McCaffery & Pasero, 1999).

Chronic pain syndromes are often the result of

traumatic injury (Muse, 1986).

May lead to:

Chronic Pain Syndrome
Pain becomes focus of life
Relationships become altered
Sometimes the result of acute, unrelieved pain
such as multiple trauma, phantom limb
pain after amputation, repeated back surgeries
Sometimes stems from neuro-muscular
disorders such as fibromyalgia, rheumatoid
arthritis, multiple sclerosis

Chronic Pain
Physicians and emergency departments may
cringevery complex, time consuming, no
easy answers or quick fixes
Behavioral medicine may be an approach
learning different coping mechanisms,
biofeedback, non-opioid interventions

Treatment of Pain
Historically, undertreated or untreated
Not considered a priority
Minimal knowledge base effective
interventions by healthcare providers
Fear of addiction
Fear of misdiagnosis
Fear of weakness

Why have people continued to

suffer?
The study of pain is relatively new
Lack of knowledge concerning harmful effects of
unrelieved pain
Personal biases
Populations at high risk:

Cognitively impaired
Very young, very old
Trauma, hemodynamically unstable

he cant even talk, hes not in pain

what if we bottom out the B/P?
its not that important right now, wait
until surgery

Youthe patient
Be knowledgeable
Ask your physician/surgeon BEFORE your

surgery
If not satisfied, get second opinion
Take pain seriously
Take analgesics when you need them, dont
save them for later
Avoid peaks and valleys

Pain
Exacts a broad toll on the psyche in terms
of physical and emotional suffering (Hedderich &
Ness, 1999)

We have the science, but are we

making any progress?

Pain is a more terrible lord of mankind than

death itself.
Albert Schweitzer

When the music changes, so must the

dance.
African Proverb